Electronic medical records save lives

Funding cuts threaten progress in the fight against HIV/AIDS

Worldwide, more than 40 million people are living with HIV, two-thirds of whom live in Africa (UNAIDS 2022). Daily antiretroviral therapy (ART) extends life for decades and prevents new infections (Cohen et al. 2011), and is now widely available thanks in large part to the President’s Emergency Plan for AIDS Relief (PEPFAR), which has been credited with saving tens of millions of lives since its launch in 2003.

To treat patients effectively, HIV clinics must offer more than just medicine. They also provide counselling and support, and actively trace patients, at home or by phone, who have lapsed from care. Ensuring continuity in treatment – without gaps in prescription refills – is critical both for patient health and preventing community transmission. This is no easy task, as a single clinic may be responsible for thousands of HIV patients, each with a need for frequent prescription refills. Millions of HIV patients in sub-Saharan Africa lapse from care each year, causing unnecessary new infections and deaths, and prolonging the epidemic (Genberg et al. 2015, Hoffman et al. 2017). 

As global policy has shifted, with international aid dwindling, clinics face daunting challenges. To sustain progress, countries, clinics, and communities must do more with fewer resources.

Can digital health innovations help?

Digital health innovations offer a potential solution. Digital nudges such as SMS reminders have shown positive but modest effects on ART adherence (Pop-Eleches et al. 2011, Mbuagbaw et al. 2013). System-level innovations show more promise by improving efficiency at scale. Evidence from the US suggests that electronic medical records (EMRs) can be used to improve efficiency, and even prevent neonatal deaths, by simplifying the process of searching patient records and flagging those in need of follow-up (Miller and Tucker 2011). EMR systems could be even more impactful in low-income countries, where healthcare systems are stretched due to underfunding and high patient volumes.

The success of EMRs in Malawi

Despite being one of the poorest countries in the world, Malawi has had a robust response to the HIV epidemic, yielding impressive results. By 2021, 85% of Malawians living with HIV were on treatment and virally suppressed, compared with a rate of 73% across East and Southern Africa (UNAIDS 2022). Malawi’s success was made possible by an efficient healthcare system: its HIV clinics manage to provide medication, counselling, and other supportive services to nearly one million people living with HIV. 

Early in the epidemic, as patient numbers started to rise, the Ministry of Health decided to adopt an EMR system (developed by local NGO Baobab Health Trust) to improve patient service, record-retrieval, record-keeping, and continuity of care given the high volume of patient records. Between 2007 and 2019, 106 HIV clinics replaced paper records with touchscreen-based systems that allowed staff to access a patient’s medical history instantly and receive guideline prompts. Importantly, EMRs in Malawi were designed to improve clinic operations by automatically generating lists of patients who had missed their most recent appointments (see Soyapi Mumba’s TED Talk on the Malawian EMR system).

Figure 1: The Malawian EMR system

The EMR system reduced patient deaths by 28%

In our research (Derksen, McGahan, and Pongeluppe 2025), we use an event study design to evaluate the impact of EMR adoption in Malawi on the retention of patients in care and on patient deaths. We compare outcomes before and after EMR adoption, using clinics that had not yet adopted as controls.

We find that EMRs had a dramatic effect on patient survival:

• Deaths fell by 28% within five years of adoption.
• Children benefited the most. Mortality of patients under the age of 10 dropped by 44%.
• By 2019, EMRs prevented approximately 5,050 AIDS deaths.

Figure 2: Reduction in patient deaths post-EMR, with clinic and year fixed effects

The key mechanism is better patient retention. Patients served by Malawi’s EMR-enabled clinics are less likely to lapse from care for long periods of time, and the total number of patients returning for prescription refills is higher than in clinics without EMRs. The EMR system makes patient tracing much more efficient: rather than searching through paper records, clinic staff can quickly identify patients who had lapsed from care using the auto-generated lists. This enabled staff to contact lapsed patients and encourage them to return. Importantly, these gains were not driven by changes in drugs, more staff, or longer clinic hours. Instead, the EMR system led to gains in managerial efficiency: better data management allowed clinics to do more with the same resources and treat more patients with the same staff.

Health systems innovations can deliver remarkable returns

The Malawian EMR system achieved life-saving impact at the astonishingly low cost of approximately US$448 per averted death. By comparison, some of the world’s most effective health interventions cost around $4,500 per life saved (GiveWell 2022). Introducing EMRs in American hospitals costs approximately $531,000 per baby’s life saved (Miller and Tucker 2011). 

Policy implications

1. The urgency of digitisation. Digital health systems should be seen as a basic priority for healthcare systems, and not a technological luxury for the developed world. EMRs can be adapted to local infrastructure and cultural contexts, and deliver truly outsized impacts in clinics that are overburdened and understaffed.
2. Efficiency matters. Technology that improves efficiency in clinics and health systems is as important as medical innovation. Malawi’s fight against HIV is often highlighted as a global success story. Yet, Malawi did not have better access to medical supplies than other countries, and, if anything, faced a more serious health burden with fewer resources. The decision to adopt EMRs allowed Malawian clinics to manage data efficiently, thereby keeping more patients alive and in care.
3. Catching critical cases. In both rich and poor countries, EMRs deliver lifesaving impacts by flagging critical cases in need of follow-up and quickly alerting healthcare staff to take action. Young children, who are vulnerable and reliant on caregivers, appear to benefit most. This mechanism suggests that EMRs may improve outcomes for patients with other diseases requiring follow-up and early intervention, such as tuberculosis, child immunisation, or chronic conditions like diabetes.

References

Cohen, M S, Y Q Chen, M McCauley, et al. (2011), “Prevention of HIV-1 infection with early antiretroviral therapy,” New England Journal of Medicine 365(6): 493–505.

Derksen, L, A M McGahan, and L S Pongeluppe (2025), “The lifesaving impact of electronic medical records for HIV patients,” Review of Economics and Statistics [forthcoming].

Genberg, B L, et al. (2015), “The health care provider experience of HIV treatment in sub-Saharan Africa,” AIDS Patient Care and STDs 29(11): 1–9.

GiveWell (2022), “Cost-effectiveness models.”

Hoffman, R M, et al. (2017), “Retention in HIV care in sub-Saharan Africa,” PLoS Medicine 14(10): e1002324.

Miller, A R, and C Tucker (2011), “Can health care information technology save babies?,” Journal of Political Economy 119(2): 289–324.

Mbuagbaw, L, et al. (2013), “The Cameroon Mobile Phone SMS Trial (CAMPS): A randomized trial of text messaging to improve ART adherence,” PLoS One 8(12): e85017.

Opuni, M, J E Sanchez-Morales, J L Figueroa, A Salas-Ortiz, L M Banda, A Olawo, et al. (2023), “Estimating the cost of HIV services for key populations provided by the LINKAGES program in Kenya and Malawi,” BMC Health Services Research 23(1): 337.

Pop-Eleches, C, et al. (2011), “Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting,” Science 329(5993): 1256–1259.

UNAIDS (2022), “Global HIV & AIDS statistics — Fact sheet.”