information and communication technologies are currently being implemented in healthcare settings with the belief that they can contribute to improved efficiency , access and quality of healthcare services ( 1,2 ) . among these technologies , electronic medical record ( emr ) systems are recognized as one of the prime transformers of healthcare and a central element in health information systems ( 2 ) . from a care perspective , emr systems are expected to improve the accuracy of patient care information recorded in health records , support clinical decision - making , and improve accessibility of patients ' healthcare information for continuity of care over space and time ( 3 ) . from a managerial perspective , emr systems can generate health care statistics , which are crucial in the management and planning of health services , thereby , improving the quality of routine health data in health systems ( 3 ) . the implementation and use of emr systems in developing countries has been examined for over a decade and reported benefits of using this technology have included reduced waiting time for patients , reduced medication order errors , guiding healthcare protocols and simplified generation of mandatory reports to higher authorities ( 4 ) . due to low healthcare budgets in developing countries , the use of free and open source software is particularly advocated as a strategy to eliminate licensing costs for sustaining the system . this has resulted in the development of various free and open source emr systems ( 5 ) . emr , electronic patient record ( epr ) , computer - based patient record ( cpr ) , and electronic health record ( ehr ) are all terms that have been used interchangeably to refer to a collection of electronically maintained information regarding an individual 's health status and health care ( 6 ) . however , emr , epr and cpr often refer to records implemented at a single or several related healthcare institutions , while ehr is often associated with a record containing all the personal health information of an individual during their lifetime , entered ( or accepted ) and accessible by healthcare providers distributed on multiple sites , including all ambulatory care settings at which the patient receives care ( 6,7 ) . in this sense , the ehr is an integrated , centralised record , and constitutes the ultimate goal that national health systems aime of achieve ( 8) . another related term that has emerged is that of  personal health records , which is similar to ehrs , but is managed by the individual instead of health institutions ( 9 ) . medical records , whether in paper or electronic form , serve multiple purposes within healthcare . their function is to create a basis for the historical record , support communication among providers , anticipate future health problems , record standard preventive measures , identify deviations from expected trends , provide a legal record , and support clinical research ( 10 ) . however , paper - based medical records have limitations in that they may be inaccessible when in use by someone else or if misplaced , there may be missing data in the records due to oversight of the health provider , the data may be difficult to read , the records increase in size over time , there is redundant recording of data in different locations , and it is tedious to extract data for clinical research . emrs are expected to have positive effects on access to data and the quality of the data since they can be accessed whenever needed and the documentation is more legible ( 10 ) . a computer can also improve completeness and accuracy through validation checks on data entered , and prompts on missing data . in addition , emrs are expected to improve the efficiency of the care process in terms of time efficiency , as well as improving the quality of care rendered through , for instance , increased adherence to protocols and reduced medical errors ( 11 ) . furthermore , ultimately , emrs are expected to improve the clinical outcomes in terms of the health status . however , its acceptance clinically is controversial as there are factors that affect clinical outcomes ( 12 ) . apart from these benefits on patient care , secondary uses of emr data in administration , disease surveillance , management and monitoring of the services are also expected to improve health services ( 13 ) . other expected benefits are reduced financial costs over time through savings on , for instance , billings , transcription costs , patient cycle time , utilisation of services and support staff salary ( 14 ) . nevertheless , the negative effects of emrs have also been reported . for instance , despite emrs improvement of access to records , it may be difficult to conduct a search and efficiently review the information in the record ( 11 ) . furthermore , emrs may impose additional administrative work tasks on already heavily burdened health providers ( 15 ) . emrs may also foster errors in the processes of entering and retrieving information , and in communication and coordination ( 16 ) . in addition , car et al ( 13 ) have indicated that the quality of data in emrs varies due to sociotechnical factors surrounding individual users . other concerns with emrs have included issues regarding privacy and confidentiality , hardware problems , system failures , time required to learn how to operate it , and decreased patient - physician interaction . thus , the abovementioned studies revealed mixed effects of emrs on care processes and outcomes . the benefits of emrs are , therefore , considered to be dependent on the quality of the implementation process and the extent to which decision support is integrated ( 17 ) . these factors are : comprehensiveness of information , duration of use and retention of data , degree of structure of data , and ubiquity of access . intrinsically , these issues are associated with the system 's functionality and design , and the development process . emrs are not simply an electronic version of the paper record , but constitute a part of a comprehensive system , which has additional information management tools ( 18 ) . however , recent findings indicated that a comprehensive emr system should comprise the following functional components : an integrated view of patient data , clinical decision support , clinician / provider order entry , access to knowledge resources , integrated communication support and analysis of aggregated data ( 19 ) . an integrated view of patient data stems from the provider 's need for a historical overview of the patient 's health status . this creates a need for the exchange of health information between different systems for the continuity of patient care among different healthcare service providers ( 20 ) . however , achieving such integration is not a simple task as it requires implementing different types of standards , i.e. , system , vocabulary , messaging and security standards . hammond and cimino ( 21 ) also indicated a need for standardized identifiers for individuals , healthcare providers , health plans , and employers , that could be recognized across systems . decision support functionality is considered crucial when dealing with decisions associated with diagnosis and therapy . computers may assist in the diagnosing of a disease based on the individual patient data , and in determining the best treatment based on evidence . the evidence may be based on , for instance , clinical guidelines and care protocols ( 22 ) . decision support functionality is considered most effective when provided at the point of care where the provider formulates their assessment of a patient 's condition and makes relevant decisions . it is , however , recommended that the applications allow the provider to override a system - provided recommendation and select an alternative action . the provider order entry functions relate to the ordering of laboratory tests , prescription of drugs or creating referrals to other allied health services ( 22 ) . the use of decision support functions in these activities is considered essential , as previously mentioned . furthermore , access to sources of knowledge is another functionality that is considered important for supporting the decision - making process for a particular patient ( 15 ) . the functionality of supporting communication among different healthcare providers is considered important with the distribution of the care process . thus , communication tools that enable the sharing of information ( e.g. , lab results ) within the emr are advocated . communication with a patient , for instance , through email , is another aspect that is considered important . in developing the required functionality , primarily , for the benefits of emrs to be achieved , it is required that the data be structured and coded to a certain degree ( 23 ) . however , entering structured data requires increased effort from providers , who are more accustomed to recording narrative textual data on paper - based records . the effort required in entering data is one of the reasons for the limited use of emrs by providers during patient consultations . there are three data entry methods that can be used : transcription of dictated or written notes , data entry from structured encounter forms , or direct entry at the point of care ( 23 ) . the most commonly used approach is data entry , which is carried out by support personnel using structured encounter forms that are completed by the care provider . for all methods , it is important for the user interface design and the physical input / output devices to be appropriate for the user 's requirements and work context ( 24 ) . concerning the user interface , a basic design principle in relation to navigation , layout , and color requires it be kept simple ( 25 ) . the use of symbols in emrs is considered important for enabling quick access and enhancing usability . in addition , incorporating different types of validity checks is recommended for error prevention during data entry . guest and conrick ( 25 ) further indicated that incorporating the following elements could assist in reducing or preventing errors : menu selection ( as opposed to form completion ) , no alphabetical characters where numbers are expected , checks prior to proceeding with major actions , and feedback on errors . in relation to layout , a design that appropriately groups information by function and reduces the overall information density on a screen is recommended . furthermore , confidentiality and privacy are central concerns in the use of emrs , and therefore authentication and access control are important in the design of such systems . it can be concluded that health information technology in the form of electronic medical systems is evolving and is benefitting the medical community in numerous ways .
implementation of electronic medical record ( emr ) systems within developing contexts as part of efforts to monitor and facilitate the attainment of health - related aims has been on the increase . 
 however , these efforts have been concentrated on urban hospitals . 
 recent findings showed that development processes of emr systems are associated with various discrepancies between protocols and work practices . 
 these discrepancies were mainly caused by factors including high workload , lack of medical resources , misunderstanding of the protocols by health workers , and client / patient practices . 
 the present review focused on the effects of emrs on patient care work , and on appropriate emr designs principles and strategies to ameliorate these systems .