Journal of Health Informatics in Developing Countries

Submitted: February 19, 2010 Accepted: March 16, 2011

A Web-Based Electronic Medical

Records and Hospital Information
System for Developing Countries*
Thuan D. NGUYEN, MD, PhD1,, Hai D. VU, MSc1,, John G. WEBSTER, PhD2,@,
Amit J. NIMUNKAR, PhD2,
1
Department of Biomedical Engineering, Hanoi University of Science and Technology,
Hanoi, Vietnam
2
Department of Biomedical Engineering, University of Wisconsin–Madison, Madison,
WI, USA, 53706

Abstract. We researched the infrastructure and current medical data management

systems in Vietnam and designed an electronic medical record keeping system to
acquire, process, store and share health information in a fully automated computer
network-based system. The modules in the system have automated data acquisition
from Ultrasound, Digital Radiography, CT scanner, MRI and Laboratory stations, and
manage pharmacy and financial information and other related activities in the hospital.
Database servers currently store personal information along with text data, image data
and will store video data in the future. The system will allow the patient to login and
review online their medical records at home. The system was tested in the Biomedical
Informatics Laboratory at the Hanoi University of Science and Technology and
implemented in Khanh Luong hospital in Hanoi, Vietnam. It meets the needs for
healthcare in developing countries with low investment cost, ease of implementation,
and convenience for doctors and medical staff.

1. Introduction

According to statistics from the Ministry of Health MoH-Vietnam, in 2008 Vietnam

had about 1,000 public and private hospitals with a total of 200,000 beds. With a total
population of about 86 million people, every year the hospital treated about 8 million
patients. The total number of doctors, nurses and medical staff in the hospitals is about
500,000 people.1 The MoH-Vietnam estimates that about 100% of the central or
provincial hospitals and 30% of suburban hospitals have Local Area Network (LAN),
high speed Internet connection and their own website.2 The World Economic Forum
reports, in Vietnam the number of people using computers is 9.51/100, Internet users
are 20.45/100, broadband Internet subscribers are 1.48/100, subscribers using cell
phones are 27.16/100, land-line telephones are 32.65/100 (2007), secure Internet
servers are 0.6/million (2007), and International Internet bandwidth (MB/s) is

@
Correspondence to: John G. Webster, 2148 ECB, Department of Biomedical Engineering, University of
Wisconsin–Madison, Madison, WI, USA, 53706, Tel: 608/263-1574, Fax: 608/265-
9239, webster@engr.wisc.edu

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1.44/10,000.3 The Vietnam Report predicts that by 2012, in Vietnam the number of
Internet users will be 36/100, broadband Internet subscribers will be 3.5/100 and cell
phone
subscribers will be 120/100.4 Thus, with the current infrastructure of information
technology (IT), in Vietnam, there is a strong trend towards the application of IT and
communications to develop hospital information management, especially for electronic
medical records (EMRs) management and remote medical services to patients (e-
hospital).1,2 Also Vietnam ranks 16th in the E-Participation Index which assesses the
quality, relevance, usefulness, and willingness of government websites for providing
online information and participatory tools and services to the people (2008).3 We have
studied the features of the EMRs and compared them to paper-based methods using
different criteria. We expect individual hospitals in Vietnam to: save $86,400 in five
working years,5 decrease error activity by 17.4%, and reduce patient total time per visit
by 22%.6 With the economic development of Vietnam, more and more high tech
medical equipment is being purchased by hospitals for patient treatment. Thus
increasing data in the form of diagnostic images, test results as well as information
from examinations, doctor’s diagnoses and therapeutic methods are generated and
currently stored in the form of films and paper in booklets. This has caused difficulties
in archiving, management, and searching, especially for patient health information
sharing in healthcare facilities in Vietnam.1,7 Using research results, we analyzed and
designed a model based on a distributed control web-server, capturing, managing,
storing and sharing electronic medical records for application and conditions in
developing countries such as Vietnam.

2. Background

2.1. Analysis of healthcare in Vietnamese hospitals

We researched hospitals in Vietnam and studied patient medical information storage,

management and the available IT facilities. We found that most of the hospitals used
manual methods for information storage and management, consisting of papers and
films in booklets. Some hospitals also used personal computers to manage and print the
patient data in a simple and discrete way. Currently there are systems available to
network these computers to allow data storage, preservation and sharing. The test
results of patients are currently written on paper from results obtained through medical
devices, or printed out from them. Subsequently, they are then physically stapled to
paper records and handed to the patients.8,9 Doctors write diagnostic results as well as
therapies needed for recovery of patients in medical examination books. Moreover,
many healthcare facilities offering treatment to the patient will provide a separate
medical examination booklet to the patient. Thus the patient ends up carrying multiple
medical examination booklets from various health care providers, often confusing them
and making retrieval of medical data difficult for doctors. Manual paper-based storage
methods, though simple and easy to implement, cannot be used to manage large
amounts of patient information. Also it is an inefficient means to store, search and
share data. Thus there is a need to develop EMR keeping systems for hospitals and
healthcare centers in developing countries such as Vietnam.

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2.2. EMR systems for developing countries such as Vietnam

EMR systems have the potential to transform heath care in terms of cost saving,
reducing error and sharing medical information.10 Telemedicine applications in these
low resource settings may serve as the only means to reliably obtain healthcare.11–13
Some of the EMR systems developed in Vietnam and used locally are:
Medisoft2003 is software designed by researchers from the MoH-Vietnam and
implemented in some of the hospitals in Vietnam. Medisoft2003 is used to maintain
epidemiological information on the health and illness of the general population for
preventive care. The hospitals report the epidemiological statistics to the MoH-
Vietnam.1,2
HTMedsoft is a software designed by Medsoft-Vietnam Co., Ltd and used to
manage patient medical and pharmacy data, record financial and billing transactions
and manage medical staff information. This software system is implemented at various
clinics around Vietnam.2
Some of the EMR systems, which were developed outside Vietnam and could be
applicable to hospitals in Vietnam, are: Management systems such as Picture Archiving
and Communication System (PACS), Radiology Information System (RIS) or Hospital
Information System (HIS). These systems could be applicable for managing patient
data in hospitals in Vietnam. However, due to very high investment costs along with
the requirements of network communication facilities these systems are not currently
available in hospitals in Vietnam.13–15
Some open source software such as VistA, Care2x and OpenMRS can be
developed for deployment in hospitals in Vietnam. But the software is primarily
focused on medical management for text-based patient data, most of the times the
interface is in English, and is not widely implemented in hospitals in Vietnam.13,16,17

3. Design Objectives

3.1. BK e-Hospital Software Model

The BK-eHospital EMR software model was designed based on the research and
analysis of health facilities in Vietnam. This model shown in figure 1 is suitable for the
majority of hospitals in Vietnam in need for management, storage and sharing of a
large number of patient medical records. To overcome shortcomings in the
management of information at hospitals in Vietnam, every patient will have a unique
Patient Identification (PID). This will allow all information related to patients to be
included in the server database according to their PID. Once patient information is
transmitted from clinical stations to the database, the doctor will login to the system
using the unique PID and view all patient information on a server database to assist in
the diagnosis and treatment. In addition, the system will provide remote medical
services such as online information for patients through login from the Internet or share
patient information to other hospitals when patients require hospital transfer.7,8
The BK-eHospital software records the patient medical data in two formats (a)
Text and (b) Image. The Text data will be generated primarily at the patient registration

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Figure 1: BK-eHospital software system model to automatically acquire store, manage and share patient
medical data.

stations, clinical, financial, pharmaceutical information, and auto-acquisition results of

the examination in the laboratory stations via RS232 interface and from the system
(PID, password access and others). The Image data will be generated from the data
acquisition primarily from the imaging stations (Ultrasound, Digital Radiography X–
ray, Computed Tomography CT, Magnetic Resonance Imaging MRI and other imaging
devices), through software modules communication between computers and imaging
equipment. Image data will be converted to common formats of the Windows operating
system and transmitted to the server database following the PID of the patient. Image
data requires more space and resources, so this will be a key point to evaluate the
effectiveness of our system in Vietnam compared to traditional methods and other
modern systems such as PACS or RIS. Table 1 compares the main parameters of
medical information management models.7,14 Table 1 shows that the BK-eHospital
model is designed in accordance with the conditions of Vietnam today. The system is
designed to ensure communication of medical image information, adequate image
quality for diagnosis, the ability to store and share information, and also very low
investment and operating costs.
Table 1 : Comparing the important parameters of the Paper-based, BK-eHospital and PACS, RIS model

Parameter Paper-based BK-eHospital PACS, RIS

Investment costs – Very low Very high
Operating costs Very high Very low High
Time patient waiting Very long Short Very short
Speed transmission – Fast Very fast
Image quality – Medium High
Storage capacity Limited Very high High
Ability to share Limited High Very high

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4. System Description

4.1. Design Scheme of Algortihm and Database for the BK-eHospital System

Figure 2 shows the flowchart of the algorithm of the BK-eHospital system. First,
patients will be registered at the registration station, if it is a new patient, the system
will create a new PID, a blank record database, new Username and Password that
corresponds with this PID. Next, the patient will go to the general doctor station with
the PID that has been provided. Based on the PID, the doctor will login to the database
to review the basic information on the patient to diagnose the patient’s health. In case
of the need for additional tests for the diagnosis, the doctor will put a request for testing
into the database of the patient. The patient will then be scheduled for tests
corresponding to the request made by the doctor. At the test station, the medical staff

Figure 2: Algorithm of the BK-eHospital system for medical record management.

will sign into the database to check the necessary information. If the request is valid
they will perform tests and submit the results to the database. Then the patient will
return to the general doctor station to get the medical examination results and their
treatment therapy. If necessary, patients will go to the pharmacy station to buy drugs
before leaving the hospital. At home, at other hospitals or other places where the
Internet is accessible, patients can login to the system by Username and Password that

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was provided in the hospital, and review their medical records, doctor's diagnosis and
the treatment results.
Figure 3 shows the structure and the overall relations between the information
tables in the entire database for the BK-eHospital system. Because the hospitals and
clinics are quite different in size and functions, so the modules as shown in the
database should depend on the facilities of each hospital, and they need to be adjusted
accordingly. However, the database structure model shown in figure 3 will be the main
premise for development of the BK-eHospital system.1,8 The information tables
designed include: the table for the Diagnostic Ultrasound stations (US), the Digital
Radiography stations (DR), the CT-Scanner stations (CT), the MRI-Scanner stations
(MRI), the Laboratory stations (LAB) and other diagnostic stations (Other). The patient
information table (Patient) is created at the registration station, the examination and
treatment information table (Exam) is created at the doctor station, the hospitalized
information table (therapy, bed) is created at the staff station, the information doctor
table (Doctor), administrator (Admin), medical staff (Staff) are created at personnel
management stations, the pharmacy information table (Medicine), equipment (Equip),
the provider (Manufac), contract (Invoice), procedures of payment (Payment) are
created at the financial, pharmacy and equipment stations respectively.

Figure 3: Database structure of this system.

4.2. Acquisition Image Information from the imaging devices

To perform image data acquisition from imaging devices on computers we need to

solve two problems: (1) design of the hardware circuit for the computer to
communicate with peripheral devices having separate standards; (2) design of software

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for data stream acquisition to be sent from the peripheral to the computer. Our research
showed that most current medical imaging equipment has image signal output, which is
a Composite-video or S-video.2 Moreover, current computer’s communication ports
often can acquire image data via USB, PCI, LPT, LAN or WiFi standards. Therefore
we designed a circuit that can communicate to both receive image data from imaging
devices and send data to the computer using industry standards. In this model we
designed circuits according to the PCI standard to communicate with a standard video
input and output. We found this method to be convenient, easy to use, stable and low
cost.2,8 It responds to the requirement for high speed transfer of real time image data.

4.3. Acquisition Test Results from the Laboratory Equipment

Unlike the image data acquisition discussed above, the data received from the test
results from the laboratory equipment will be easier to process as it is in text format. So
the rate of data communication is slower and the information is often received as a
message. Our research showed that most laboratory devices send output data using
RS232 at the COM ports. Since the communications are available on the computer for
data acquisition, we connect the laboratory equipment and computer via RS232
interface. The software is designed to read the data sent to the computer.9 However, in
order to design the software to read the message and then determine the exact
parameters of the tests, we need to know format of the data frame the equipment
manufacturer used. Often this information is available in the technical support
documentation of the manufacturer (the service manual). If the information is not
available, we analyze the data stream format beforehand, by reading the message from
the device by software (such as Terminal, Collect, Virtual Serial Port Kit and others),
and then compare with the result displayed on the equipment to determine the data
frame structure.18

5. Status Report

The system was built by using the ASP.Net, VB.Net and C++ languages and manages
information using the SQL Server2000. Currently the system is implemented and tested
in the Khanh Luong Hospital, Hanoi, Vietnam. The experimental results showed that
the system is robust in its performance, the duration for data acquisition and transfer
rate is quick given the computer network capabilities of the hospital and, the
information storage, printing and reporting statistic modules of the software work
appropriately. The BK-eHospital system meets the current needs of the hospitals in
Vietnam and has the capability of catering to the needs in near future. The modules of
the BK-eHospital system which are currently functional include: registration and
automatically create PID stations, acquisition and processing ultrasound images, DR,
CT and MRI stations, hematology analyzer stations, biochemical, immunology,
microbiological, cellular, endocrine and urine tests stations, reviewing and processing
patient information for clinical doctor stations, financial stations, pharmaceutical
stations; administrator station; sign in and review online information for the patient.8,9
Figures 4 and 5 show the design, testing and implementation of the BK-eHospital
system for patient medical record storage, management and sharing.

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(a)

(b)

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(c)

(d)

Figure 4: Acquisition and management of medical records (a) Laboratory stations, (b) Ultrasound imaging
stations and (c) CT-scanning stations and (d) MRI stations.

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BK-eHospital system provides a login interface common for all doctors and
medical staff at the hospital. After login, the system will identify the kind of user who
has logged into the system, for example, whether the user is physician, nurse or
medical staff, financial staff, pharmacy staff and other staff members. Based on this
information the system will provide appropriate access to the database servers. The
online login interface via the internet is provided for the patients. After the patient’s
information is updated via the Registration station interface, the system will
automatically allocate PID, user and password to the patient for access to the system. A
camera will automatically capture images of patients for inclusion in the database.
Figure 5a shows the Clinical station module where the clinical doctors can access
the entire database of patients through the PID for the synthesis, analysis, diagnosis and
offer treatment guidelines for patients. For example the MRI data of patients are shown
for analysis at the clinical station. Figure 5b shows the online review module for
patients to access part of their EMR through Internet, for example the patient can
review the laboratory test results and see if the test results are normal. Figure 5c shows
the Pharmacy station module to manage all activities regarding use of medicines by the
patient in the hospital. Using the PID the pharmacists can determine the financial
procedures and drugs allocated to the patients. Figure 5d shows the financial station
module to manage of all financial activities of the patient with the hospital. Based on
PID, the financial personnel can determine the hospital fee for each examination and
treatment of the patient; and verify the procedures for completing financial obligations
to the patient.
(a)

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(b)

(c)

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(d)

Figure 5: Interface to (a) manage clinical information of the patient by the doctors, (b) view medical records
online by the patients, (c) manage pharmacy information and (d) manage billing and other financial
information.

6. Discussion

6.1. Security of BK-eHospital System

The security of the patient medical records is of prime importance and is addressed in
the BK-eHospital system. We use the administrative databases in SQL Server 2000 or
2005 that have an information table for users. The highest-level administrator of the
system who is called the “Super Admin” can login as "sa", this is the default name of
Microsoft SQL Server 2000. The password of “sa” will be set and may be changed by
Super Admin. Super Admin will have the right to create or delete as well as distribute
access to databases for the users in the system. This includes the account to login to the
system for doctors, technicians, nurses, medical staff and others. Specific access rights
given to the users in the database system are determined by the administrator of the
particular hospital. Only the Super Admin can directly intervene in the database
system, but all the operations of the Super Admin will be monitored by the system. The
other users are only allowed to add and view the patient’s record but not edit previous
information. The system will monitor any activity with the patient’s record. Therefore,
each user after login to the system will be responsible for his or her operations on the
database. Most employees are issued their Username and Password to access the
database and the computers will be kept at secure locations to prevent unauthorized
usage. To ensure the security of medical record information in the database of the BK-

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eHospital system, hospitals need to invest in two database servers located in 2 different
locations. The patient medical records will be continuously backed up in both of these
servers.

6.2. Security of Medical Records when accessed by patients

The BK-eHospital system creates and provides the Username and Password for patients
automatically based on the patient's name and a random code. The medical staff prints
out cards with login and the password information during initial registration. The
patient can change the password after their first login into the system. Patients are
advised not to share the login and password in order to maintain security of their
medical records. Patients can only view part of their medical records, which consists of
important test results, therapies suggested by the physicians, pharmacy information and
other such information under the discretion of the hospital. Sharing of the medical
records by other hospitals depends on the co-operation between the two hospitals.
Currently the BK-eHospital system requires a PID and digital photo of the patient
to help the doctor identify the patient being treated to avoid possible errors. We are
investigating the use of barcode technology to create the PID. The patient's card will
have a barcode and the medical staff will use a barcode reader to determine the PID
instead of entering the PID manually. This will make the system more efficient and
reduce potential errors during logins. In addition, when patients would login to the
system to see their medical record, along with Username and Password, the system will
ask the patients to enter in the barcode number on their card.

6.3. Cost and Implementation Issues

6.3.1. Cost for designing the system

BK-eHospital was designed using a total of around $20,000 in funding from
Ministry of Education and Training (MoET) of Vietnam. Research and
development was performed over the course of two years by 5 faculty members
and 10 students from HUST’s Biomedical Informatics laboratory.

6.3.2. Cost and technology needed of implementation of the system

Currently, the BK-eHospital is being implemented at Khanh Luong hospital,
Hanoi, Vietnam with a capacity of 300 beds. The system includes: 2 Registration
stations, 1 Ultrasound station, 1 CT station, 2 Laboratory stations, 1 MRI station, 2
Hemodialysis stations, 5 Doctor stations, 1 Admin station, 2 Manager board
stations, 1 Pharmacy station, 1 Financial station and 4 Medical staff stations.
Khanh Luong hospital has invested in 23 Personal Computers (PCs), LAN system
and 2 small servers to implement the BK-eHospital and manage the medical
records for around 30,000 visits by patients per year.
The Infrastructure needed in the hospital to implement the BK-eHospital
would consist of PCs, LAN system and at least two servers. Depending on the size
of each hospital specific requirements for the PC, LAN, and server will need to be
determined. If the hospital has 500 beds or less, the equipment requirements will
include approximately: 50 PCs, LAN and 2 small or medium servers. If the
hospital scales from 500 to 1000 beds, the equipment requirements will include
approximately 100 PCs, LAN and 2 large and robust servers.

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BK-eHospital is developed around an open-source model, so software could

be easily made available and implemented in other developing countries. Since the
system functions in a module fashion each module will need to be installed at the
respective stations as in figure 1. The number of stations may change, depending
on the size and requirements of each hospital. Currently, the BK-eHospital is
implemented in Vietnamese and English languages. However, if a hospital requires
other languages, the BK-eHospital could be easily translated.
In addition, BK-eHospital can be customized to fit the needs of each
individual hospital. We expect all the necessary tasks for implementation of the
system could be performed by 1 or 2 faculty members. These faculty members will
visit the hospital to setup the system as well as provide instructions for the users.
The implementation at a given hospital could take at least one month by the faculty
members involved in the design of this system.

6.4. Limitations

The BK-eHospital system is designed to meet the requirements of the EMR system and
provide online remote medical services for patients based on the IT infrastructure of the
developing countries. However, some problems have not been resolved as yet for
example: (a) if the US, CT and MRI machines do not automatically calculate
diagnostic parameters or if they do not have a DICOM output, the parameters need to
be calculated and entered manually into the system.14 (b) with multi slice imaging as
with CT, MRI image scanners, we cannot capture the images into the software with
time synchronization. The appropriate images are manually entered after being
reviewed by the physicians.

6.5. Future Studies

According to statistics reported in,3,4 the number of cell phone subscribers in Vietnam
has been increasing very rapidly. The BK-eHospital system will be further developed
to allow patients to access their medical records using cell phones. Patients can login to
the system by cell phone to review their disease status as well as consult with the
medical staff for advice. We plan to add more features, which include automatic
acquisition of other medical data types such as video data from endoscopy, 3D and 4D
image data, waveforms of electrocardiograms, electromyograms,
electroencephalograms, and other signals and store them in the system database.

7. Conclusion

There is a need for a web-based EMR system in Vietnam to make the medical records
accessible to hospital medical staff and patients to make the healthcare system more
efficient. The Biomedical Informatics laboratory at the Hanoi University of Science
and Technology in Vietnam has developed the BK-eHospital system through the MoET,
Vietnam to assist in providing better healthcare to the people in Vietnam. The system
would minimize errors due to manual entry of patient medical data by automated data
acquisition of medical information from medical equipment such as laboratory devices,
ultrasound, DR, CT, MRI machines and others and is currently implemented at Khanh
Luong hospital, Hanoi, Vietnam. The system also allows patients to access their

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medical information via the Internet and would provide information about their medical
tests in a timely manner and the treatment recommended by doctors for quick recovery.
The current system is more suitable for medium and small hospitals with 1,000 beds or
less and, could be implemented in a number of such hospitals in Vietnam. Currently
there are no standards in place for sharing and managing of patient health records
between different hospitals in Vietnam. Through the MoET and MoH in Vietnam we
are establishing standards to manage, store and share medical records between different
healthcare providers in the country.

Acknowledgements

We would like to thank the Department of Biomedical Engineering, Hanoi University

of Science and Technology, Vietnam; Department of Biomedical Engineering, The
University of Wisconsin-Madison, USA; Bach Mai hospital, Khanh Luong hospital,
Central Reproduction hospital in Hanoi, Vietnam for their support and encouragement.
The BK-eHospital system was designed and developed by the biomedical engineering
faculties and students at the Hanoi University of Science and Technology, Vietnam.
We would also like to thank Jonathan Baran, at the University of Wisconsin-Madison
for his helpful suggestions.

*This project was supported in part by Ministry of Education and Training (MoET), Vietnam Grant B2008-
01-150-TD.

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