We are often asked how much it costs to implement Electronic Medical Record systems in hospitals in low-medium income countries. Here are some of the factors to consider:

Open-source software: If you find software that is close to your requirements and is free and open source, this is a good way to start. There may be a community of users who can support you or the developer may provide some support (although you cannot expect too much support for free from a commercial company). If you believe that popular means good, the most widely used Open-Source EMR software is listed here ( http://blog.capterra.com/top-7-free-open-source-emr-software-products/ ). Vista, produced by the US Veterans Administration is particularly comprehensive and is becoming popular in India. In Malaysia, the Primary Care Doctors' Organization (PCDOM) distributes a free open source software for general practitioners, PrimaCare (http://traininghealthprofessionals.com/online-training/pcdom-primacare/ ). HHIMS that was specially written for hospitals in Sri Lanka (http://www.hhims.org ), is very simple medical record software that is easy to use.

Adapting the basic system: Most free software will need to be tailored to your needs, but it gives you the chance to get experience fairly quickly and is a good start to developing a system that will suit your needs.

Clinical terminologies: The longest-running clinical terminology database is the ICD (International Classification of Diseases) from WHO, now in its 10th revision. It is not very easy to use without a training course so is not so useful for data entry by clinical staff but at least it is available free of charge. A much easier database to use is SNOMED-CT and if your country is a member of the IHTSDO you can get a license to use it from your Government. You can learn about it from their site (http://www.ihtsdo.org/). The HHIMS demonstration site has the full set of SNOMED terms to show how it can be used (www.mdsfoss.org/hhimsv2).

Computer hardware: This you will have to buy, unless you can arrange for humanitarian assistance or foreign aid. Contact some of the embassies, NGOs or the UN office in your country to see if there are any such plans. The World Bank web-site may also have information on projects that might include EMR systems. To run most EMR systems, you will need a (small) server computer in the hospital to store the central EMR database. We recommend Dell servers for their low-cost and reliability - one that would cost about $US 3,000 including a UPS and an inverter power back-up with large truck batteries should suffice for a small system (<10 workstations). Each user in the hospital needs to have access to a workstation. For a typical hospital, desktop PCs (or laptops) costing about $1,000 each depending on import taxes, would be suitable. For a 200-bed hospital you will probably need about 40 such machines plus some laser printers (also about $1,000 each). Then you would need LAN cabling for the hospital (if done locally should cost about $10,000 for a compact hospital).

Consultancy and training: A number of companies and local universities provide support for users on-line and also travel to sites. For example, HardHats (http://www.hardhats.org/links/LINKSmain.html) support Vista, and Lunar Technologies (www.lunartechnologies.net) support HHIMS and give training courses on-site. You will have to pay for consultancy services however. Most consultants will program a small amount of customization of the SW and perhaps even write new modules. It's hard to put a cost on this as it depends on what is needed; on-line support with some reports written and assistance in configuration might only cost $5,000 but if you want a major re-write with translation into local language this could end up well over $20,000. On-site help usually involves travel costs for the consultants.

Summary: So there you are. Minimal cost in a developing country would be about $60,000 for a 200-bed hospital if you do it all yourself and around $100,000 if you engage a support group.  In this article we have not mentioned costs in the developed countries. There high demands on system functionality and heavy bureaucratic regulation force the prices of software up, although paradoxically hardware is often cheaper.

Prices in this article are quoted in US dollars - they are very approximate and you should shop around - not just for price but also for quality.