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

Status of EHR adoption, challenges and opportunities in LICs

This review aims to examine the status, challenges and opportunities of adopting EHR systems to enhance the quality of healthcare delivery in LICs. In most LICs, donors provide support to establish EHR systems, which usually fail for many reasons. For example, in Ethiopia, the Smart Care system, which is supported by donors, is not functioning at full scale as expected due to low economic readiness.46 It is failing at a pilot stage in many of the hospitals where the system is implemented.43 Further, Ngusie et al36 noted that, in most LICs, EHR implementation exists at the preimplementation stage. This affirms that countries should first identify organisational, technological, social and economic readiness before adopting EHR systems.46

However, in countries such as Uganda, locally developed EHR platforms are being used to enhance patient care.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. It is also in line with the findings reported in low-income and-middle-income countries.47 Therefore, LICs should work hard towards adopting open-source EMR systems which fit the shortcomings of the economy and user-friendliness.

Most of the challenges for the failure of EHR adoption in LICs were lack of training, infrastructure, management commitment, standards, consistency, interoperability, quality of systems, support, use, information, satisfaction and impact of the system.34 40 42–44 Further, Oumer et al38 added the impact of healthcare providers’ experience on affecting EHR adoption as experienced have twice higher odds of using EMR than early career workers. Most of these challenges are similar to those reported in studies conducted in middle-income countries.19–23 Furthermore, a scoping review of studies published between 2005 and 2020 on PubMed, Web of Science, IEEE Xplore and ACM Digital Library reported similar challenges as the current study.48 Therefore, every LICs needs to develop strategies, legislations, regulations and a framework of implementation that can address the mentioned challenges before adopting or implementing EHR systems.

Moreover, EHR adoption might pose unanticipated challenges to existing healthcare systems if not managed appropriately. Windle et al49 in their findings indicated the perception of clinicians on the impact of EHR in impeding the workflow and communication, and prolonging their workday. EHR implementation causes physician burn-out due to contributing factors like increased documentation, which are significantly underestimated.50 These challenges need critical attention and should be addressed during the preimplementation phase.

Despite the various factors influencing the success of EHR adoption, there are opportunities that can maximise its potential. The most important scenario is a good perception of healthcare providers in using EMR systems.43 Also, most healthcare professionals are open-minded about using such systems whenever deployed or adopted.38 Moreover, the health information exchange infrastructure in LICs is immature or absent. These findings are in line with those mentioned in the studies conducted by Amend et al51 which considers stakeholder readiness, change management, accessibility and ownership, EHR structure and external factors as key facilitators for EHR adoption.

Multiple studies indicated the impact of EHR systems in capitalising on quality in healthcare delivery.34 38–41 44 Studies conducted in countries other than LICs indicated the significance of EHR systems in enhancing the quality of healthcare in terms of safety, effectiveness, people-centredness, timeliness, efficiency, equity and provision of integrated services.52 53 This study portrayed a clear image of EHR systems adoption status, challenges and opportunities in LICs to enhance the quality of healthcare delivery.