User Perceptions and Use of an Enhanced Electronic Health Record in Rwanda With and Without Clinical Alerts: Cross-sectional Survey

Abstract

Background Electronic health records (EHRs) have been implemented in many low-resource settings but lack strong evidence for usability, use, user confidence, scalability, and sustainability. Objective This study aimed to evaluate staff use and perceptions of an EHR widely used for HIV care in >300 health facilities in Rwanda, providing evidence on factors influencing current performance, scalability, and sustainability. Methods A randomized, cross-sectional, structured interview survey of health center staff was designed to assess functionality, use, and attitudes toward the EHR and clinical alerts. This study used the associated randomized clinical trial study sample (56/112, 50% sites received an enhanced EHR), pulling 27 (50%) sites from each group. Free-text comments were analyzed thematically using inductive coding. Results Of the 100 participants, 90 (90% response rate) were interviewed at 54 health centers: 44 (49%) participants were clinical and 46 (51%) were technical. The EHR top uses were to access client data easily or quickly (62/90, 69%), update patient records (56/89, 63%), create new patient records (49/88, 56%), generate various reports (38/85, 45%), and review previous records (43/89, 48%). In addition, >90% (81/90) of respondents agreed that the EHR made it easier to make informed decisions, was worth using, and has improved patient information quality. Regarding availability, (66/88) 75% said they could always or almost always count on the EHR being available, whereas (6/88) 7% said never/almost never. In intervention sites, staff were significantly more likely to update existing records (P=.04), generate summaries before (P<.001) or during visits (P=.01), and agree that “the EHR provides useful alerts, and reminders” (P<.01). Conclusions Most users perceived the EHR as well accepted, appropriate, and effective for use in low-resource settings despite infrastructure limitation in 25% (22/88) of the sites. The implementation of EHR enhancements can improve the perceived usefulness and use of key functions. Successful scale-up and use of EHRs in small health facilities could improve clinical documentation, care, reporting, and disease surveillance in low- and middle-income countries.

Adoption of electronic health record systems to enhance the quality of healthcare in low-income countries: a systematic review

“…In terms of safety, the finding presented by Fraser et al 40 signified the role of openMRS system in supporting patient care by providing alerts. Additionally, Liang et al 39 mentioned the significance of EHR systems in maintaining patient safety features, which in turn has improved care for more than 60 000 patients in Uganda.…”

“…Liang et al 39 mentioned that the locally developed EHR platform is capable of managing patient information and related healthcare services. Further, Fraser et al 40 indicated the effectiveness of openMRS despite the infrastructure limitation in Rwanda. These all assertions prove the significance of adopting EHR systems in delivering effective healthcare services.…”

“…Five studies identified barriers to EHR adoption in LICs, as presented in table 4. Dominantly, lack of training,40 42–44 poor infrastructure,40 43 44 lack of management commitment,40 43 lack of standards40 43 44 and absence of interoperability43 are the barriers observed. Bagayoko et al 42 identified the quality of a system, support, information, actual use, satisfaction and impact as potential barriers.…”

“… 39 The openMRS system in Rwanda is also making a notable influence in supporting healthcare delivery by providing informed decisions, alerts and reminders. 40 Further, studies conducted in Sierra Leone and Angola indicated that open-source EMR systems are enhancing clinical care and clinical decision-making. 34 35 These findings show that EHR systems are currently being practised in LICs despite the challenges reported.…”

Open Source Digital Health Software for Resilient, Accessible and Equitable Healthcare Systems

“…This includes more evaluation studies to determine how effective these approaches are in real world deployments at scale. These should include measuring improvements in accessibility and use of systems by a range of users including remote or vulnerable groups and including age, gender and ethnic background [31,32]. This will allow optimal designs to be shared and adopted at scale, ready for evaluation of their broad impact.…”