Electronic medical records for health system strengthening in Nepal: a community case study of phased implementation across public hospitals

Abstract

Robust health information systems are foundational to universal health coverage, quality of care and health-system resilience, yet many public hospitals in low- and middle-income countries (LMICs) still rely on paper-based records that fragment patient histories, duplicate diagnostics and limit routine data for management and policy. This community case study describes the phased implementation and observed system-level changes of open-source electronic medical records (EMRs) across public hospitals in Nepal and reflects on transferable lessons for comparable settings. From the early 2010s, Nepal adopted open-source EMR platforms principally Bahmni, built on OpenMRS as a license-free, locally adaptable alternative to proprietary systems. Adoption accelerated after the COVID-19 pandemic and was reinforced by Nepal's 2022 Joint External Evaluation and COVID-19 Intra-Action Review, both of which called for a transition from fragmented paper-based reporting towards integrated digital systems. With technical assistance from the World Health Organization (WHO) and financing from the Pandemic Fund, EMRs were deployed through a standardized six-phase model emphasizing readiness assessment, clinician engagement, local customization and sustained capacity-building; from 2024, legacy installations were upgraded to the FHIR-aligned OpenMRS 3 interface. By May 2026, 19 government hospitals across six of Nepal's seven provinces had transitioned to functional open-source EMRs, with longitudinal records accessible across departments, integrated laboratory and radiology results, standardized electronic reporting and expanded routine data for oversight. Optimizing the whole technical environment, particularly storage and network quality rather than processing power alone proved critical. Improvements in clinical continuity and efficiency were reported by users rather than formally measured. Nepal's experience suggests EMRs are best understood as organizational transformation rather than a purely technological upgrade.