Global, Insight

Deep dive: exploring electronic health records in South Africa, Ethiopia and Nigeria

For our new series here on HTN, over the next couple of months we’ll be developing our international insights by sharing a regular deep dive into the world of health tech in different countries and continents. First up, we’re exploring electronic health records in Africa.

Barriers and facilitators to electronic health record implementation in South Africa 

Last week, a research article was published in Frontiers exploring the “barriers and facilitators to implementing electronic health records in a middle-income country”, with the authors highlighting key needs including tackling interoperability, developing underlying infrastructure, and building on existing systems.

Introducing their study and the reason behind it, the researchers share: “South Africa plans to establish a National Health Insurance fund where EHRs will be essential for monitoring outcomes, and informing purchasing decisions. Despite various relevant policies and South Africa’s relative wealth and digital capability, progress has been slow.” To examine the reasons behind this, the team interviewed public health specialists, digital health academics, government staff, managers in the private health sector, and more.

The interviews resulted in four key areas that participants felt affected EHR implementation: leadership; skills and expertise; resources, funding and infrastructure; and governance.

On leadership, participants highlighted the importance of high-level buy-in, with one commenting that they did not feel that government representatives “have always understood the full project and the implications of taking on something like that if you’re talking about national implementation”. They added that high-level buy-in “improves long-term collaborations with stakeholders”, and noted that lack of this buy-in has led in some cases to a reduction in available support, with one participant sharing that a decision was made to “get rid of the digital health unit… that was a real setback because after that there was a complete gap.”

Another area raised around leadership, was the importance of “putting the right people in place to lead and facilitate implementation”, with participants criticising the appointment of leaders based on membership to political parties as opposed to merit.

On skills and expertise, capacity was raised as key: “Part of any comprehensive strategy to implement electronic health record needs to have a strong capacity building component.” They noted the importance of skills and expertise being found across the board, in government as well as in healthcare.

The challenges of recruiting in public health were noted, with comments that “without sufficient skills, there may be limited progress”. They also commented on their belief that clinicians should be running information systems, with one participant stating: “So often the people that decide on systems are not the people that use the systems. So, the decisions are often taken by people … who do not understand the needs of the user. They go out and procure systems without realising that they’re not solving the problems that the users had in the first place.”

The importance of having a highly trained health care workforce was highlighted, with interviews raising the need to improve computer literacy. “Training needs to start early and accommodate everyone that joins the public health workforce,” one participant said, “starting with training people at universities. Pre-service is as important as in-service training. But training is an ongoing thing… it’s not a one off.” On this note, one participant pointed out that failure to train and prepare the workforce can lead the security issues: “The systems are pretty much sewn-up with encryption, protection, back-up, data security, disaster recovery, but they’re only as strong as the weakest link, which is us humans”.

On resources, funding and infrastructure, participants said that “significant investment” is required and noted that in South Africa, they tend to rely on secondary infrastructure from private sector companies “with whom we now have contractual issues”. They added that “much of the plans to develop a digital health eco-system are hampered by poor connectivity”, stating: “We can’t do what we need to do. Nearly 40 percent of public health facilities have no reliable connection to the internet. How do we run a real time data system that’s trying to run the national health insurance with portable health records?”

In line with infrastructure needs, one participant commented on the challenges around lack of storage facilities; another raised the issue of working in siloes, noting that they have 10 departments of health, a national department, and nine provinces. “They’re all autonomous, but they don’t have their own data centres, they all can run whatever they want to run. As a result, it’s really hard to do any kind of migration of data to a central data repository.”

With regards to resources, the interviews raised the importance of assessing what resources are needed in different areas of the country, with one participant calling for “a proper situational analysis done on what is available”.

Finally, on governance, the participants said that it is “absolutely critical” to make sure that there is “sufficient alignment of vision between national and province”. They also called for “better monitoring mechanisms for tender systems” to “combat corruption and improve accountability”; called for “appropriately qualified and skilled authorities to prioritise digital health”; and called for “a transparent and multi-disciplinary panel of experts to help with planning and decision-making.”

Concluding their study, the authors note that the Western Cape Province has, over a 20-year period, been able to create a provincial digital health eco-system and EHR. “Much of this progress has been attributed to consistent and high-level political support and sufficient technically capable staff both inside and outside government,” the authors acknowledge. Whilst South Africa has the “necessary policies” in place, they add, “the progress in implementing electronic health records has been limited.” They suggest that “drawing lessons from successful examples such as the Western Cape Province” would help in “guiding the country towards a digital health ecosystem and an electronic health record system.”

Read the study in full here.

Exploring healthcare professionals’ satisfaction with health information system in Ethiopia 

Moving on to look at attitudes towards existing systems, let’s take a look at a study published last month in Frontiers which evaluates healthcare professionals’ satisfaction with the district health information system in south west Ethiopia, with perspectives from nearly 400 professionals explored.

The researchers found by distributing a questionnaire that overall user satisfaction was low, with 54 percent of respondents describing themselves as unsatisfied with district health information.

System quality, service quality and computer literacy were all highlighted as having a “direct positive effect on system use and user satisfaction”, with the authors noting that increased system use “should result in greater user satisfaction and beneficial effects on personal productivity.”

The results also highlighted that computer literacy appeared to be “the most important factor for enhancing system use and user satisfaction.” As such, the authors concluded that “specific user training [is] required for the success of the district health information system in Ethiopia”, and they added that managers “should offer additional basic computer courses for better use of the system.”

The study can be found in full here.

Adopting medical records in developing countries: a study from Nigeria 

Finally, let’s take a look at a multi-state study of the Nigerian healthcare system, also from Frontiers, which focuses on adoption of electronic medical records in developing countries.

The key objective of the study was to “investigate the propensity of clinicians and senior management personnel in healthcare facilities to adopt EMR and evaluate the contextual factors that impact or impede adoption”, with the researchers emphasising how they “deliberately set out to study a good mix of decision makers and system users.”

Using data from 1,177 survey respondents, the researchers found that “usefulness, critical success factors, awareness and relative advantage significantly influence clinicians’ intention to adopt EMRs.”

Usefulness, the study highlights, had “the highest impact to increase adoption of EMR”. Results showed that for every one unit increase in user perception of usefulness, user propensity to adopt EMR increased by a factor of 18.35.

“This is followed by critical success factor, awareness and relative advantage,” the authors specify. Infrastructure availability and ease of use were “also important in the model” though they were “not statistically significant.”

In terms of negative impact, user perception of risk and safety of their data were shown to decrease user propensity to adopt EMR.

Moving on to explore recommendations as a result of these findings, the authors point out that “in Nigeria, EMR is a new technology in the nascent stages of adoption in several states”; therefore the government “should be actively involved, designating appropriate agencies to partner with the federal ministry of health to develop regulatory policies and guidelines.” In addition, “there should be increased funding to health and functional health records department in all health facilities.” The authors also state a need to improve infrastructure to ensure adoption, implementation and sustainability of EMR, adding that the government “should fast-track the development of an e-health infrastructure, such as internet backbone or satellite technology, as well as the spread of high-speed broadband data services.”

From a healthcare facility perspective, the study suggests that management should invest in training, infrastructure installation and maintenance, with focus on setting up “an effective system that will deal with feedback promptly.” In preparation for the adoption of digital interventions, the authors say, hospital management “needs to be ready to commit the resources” required “to make them successful”, suggesting that electrical power supply and the deployment of adequately trained staff to run ICT departments should be “topmost on the priority list.”

Building on the study findings, the authors recommend early involvement of stakeholders to build knowledge of end user requirements and reduce resistance to change, along with identifying and communicating benefits to stakeholders as much as possible. In addition, hospital management “should be involved in enforcing policies on EMR, training and motivating the workforce.”

In addition, the authors recommend that EMR system vendors should be expected to demonstrate usefulness and ease of use to healthcare workers “beyond reasonable doubt.”

On an individual level, the study states: “Improving awareness will encourage staff to invest their time and finances to educate and upgrade themselves in preparation for adoption of IT innovations which is critical to improved patient care and service delivery.”

Read the study in full here.