Introduction
Health information has been defined as the ‘foundation’ for better health, the ‘glue’ for sticking and holding health systems together and the ‘oil’ lubricating these systems to keep them running.1 Health information is the information about people’s health that describes the occurrence, prevalence and causes of major illnesses, diseases and infections along with the availability, use and effectiveness of remedial actions.2 The availability of standardised reliable health information is indispensable for observing, measuring and monitoring the coverage, quality and outcomes of health services. Likewise, the timely capture and analysis of data obtained through surveillance of health threats and epidemics informs strategies for their prevention and containment.3 Providing the infrastructures and technologies that can enable data to be accurately collected, exchanged and analysed in a timely manner can thus aid in the management of individual patients and strengthen the governance and effectiveness of health systems and improve population health.4
The World Health Organization (WHO)’s Framework for Action has identified health information as one of the six essential building blocks of effective health systems.5 The other five are health workforce, leadership and governance, service delivery, financing, and medical products, vaccines and technologies. According to Health Information for All 2015 (HIFA 2015), the availability and use of appropriate and reliable health information is essential to the achievement of Millennium Development Goals (MDGs). HIFA was founded in 2006 with the aim of ensuring that every person in the world will have access to an informed health care provider (see www.hifa2015.org). Furthermore, the United Nations’ (UN’s) High Level Panel on the post-2015 Development Agenda recently called for a ‘data revolution’ for sustainable development, with a new global initiative, Global Partnership on Development Data, to improve the quality of information and statistics available to diverse interested stakeholders – people, government, international organisations, foundations and the private sector.6
These goals will only be achieved when interested stakeholders are prepared and able to participate in health information exchange (HIE) across health providers, organisations and systems. Such stakeholders include doctors, nurses, health workers, pharmacists, managers and patients in order to support the delivery of optimum quality of health care at the community, district and national levels. For example, information is required at individual and community levels to meet the needs of the local population; at the district level, to help health managers and planners to make judgements and decisions regarding the health system and the effectiveness of health facilities; and at the national level, to make strategic decisions about resource allocation.7 Moreover, co-operation is required among a wide variety of specialists including health care providers, researchers and policy makers for the development of robust systems that can provide reliable, relevant and usable information to support delivery of effective health care services.8
Sound information is also indispensable for monitoring public health outcomes and actions such as planning, programming, policy making and monitoring. Similarly, it is required to ensure accountability of resources and to evaluate the progress of nations against global objectives such as the MDG, which can be improved through strengthening information management at all levels of countries’ health systems. 9,10 Better data and statistics can enable governments to track progress in a timely fashion.6 Accurate health information can empower stakeholders to identify the neediest, for example malaria or human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) patients, and determine whether they are receiving required essential services and facilities. The absence of relevant and reliable health information is a major contributor to preventable deaths and sufferings.11
According to the World Bank (WB), a developing country is one in which the majority of the inhabitants live on low wages, with far fewer public services available to them than those available in the highly industrialised nations.12 Gross national income (GNI) is the main criterion used by the WB to classify economies into low- and middle-income countries (LMIC), which sometimes are also known as developing economies.13 These developing economies are divided into different groups, with respect to GNI per capita, for example (1) low income: $1035 or less; (2) lower middle income: $1036–$4085; and (3) upper middle income: $4086–$12,615. Developed or high-income countries, on the other hand, have a per capita income of $12616 or more.
Lack of access to health information makes it unlikely that LMIC will be able to realise the goals of truly ‘informed health care’ in the near future, as has been envisaged for higher income regions.14 Because many LMIC are unable to generate reliable, complete and timely information about patient health, disease, care and outcomes, their progress in meeting key heath indicators such as the MDG cannot be easily established. Such data are often incomplete and there are frequent significant time lags between data collection periods. 15 For example, over 40 LMIC are incapable of tracking progress on extreme poverty and hunger due to insufficient data.16 Many national authorities are not able to report reliable health-related information to international organisations and donors such as UN and WHO due to poor information capture and management.
Studies on health information systems (HISs) in LMIC have identified a range of barriers to various types of health information exchanged and shared between suppliers/producers, consumers and users.2,17–20 Fragile HISs are increasing dissatisfaction and frustration among producers and users of health data. The introduction of technology and the provision of finance for strengthening weak health systems do not address all of these problems, as there are other technical, structural and sociotechnical barriers that also need to be considered.21–23 For example, HIE at the provincial or national level can only be useful if connectivity and exchange of health information exist at the individual, community or district levels in the first instance.
Given these challenges, there is a pressing need to better comprehend the barriers and facilitators to HIE at individual, provider, community, district, provincial and national levels, especially in LMIC. An appreciation of the barriers and facilitators to accessing, sharing and exchanging health information in different LMIC will allow stakeholders to better understand possible solutions to tackling the problem currently experienced with HIE.
Systematic reviews can be useful for informing the development of evidence-based strategies to address the problems faced by LMIC.24 This systematic review seeks to capture, appraise and synthesise the existing empirical evidence documenting challenges and facilitators to HIE in LMIC. It has the potential to inform guidelines for international donor agencies, national authorities and global health organisations, such as the WHO, the UN and the WB, wishing to develop effective strategies for investment in the design and implementation of HIE.
Past similar reviews/systematic reviews/studies: identifying gaps
Related similar systematic and academic reviews had been conducted, but these have major limitations.
Williams and Boren (1) studied the benefits of electronic medical records (EMR) with respect to patients, physicians and other care providers and their contribution to the development of health care delivery in developing countries. This involved searches of only four academic databases (i.e. Medline, CINAHL, COMPENDEX, Academic Search Premier), which contributed to the sub-optimal search strategy. Articles not published in English language were excluded. Another important limitation was that no quality assessment tool was used to appraise the methodologies of the included studies. The first eligible study found was from the year 1995. The study found that most of the developing countries lack the experts, funds, infrastructure and sustainable energy necessary to implement the health care technology. In contrast, support from developed countries in designing and implementing the computer-based health records in developing regions and availability of open-source software were found as facilitators.
Another systematic review by Ndabarora26 focused primarily on problems with health data quality and health information management, and evidences of best practices and use at community and district levels in LMIC to improve these. It involved searches of five academic databases (i.e. Pubmed, Medline, LISTA, CINAHL, Cochrane) and a Google search engine to search for citations, conference proceedings and disease surveillance reports from 2000 to 2011. The quality of the included studies was assessed in terms of study outcomes, but it was unclear which, if any, quality assessment tool was used. Only English language articles were included in the review. Poor quality health data, poor management of HIS and low usage of health information were found to be the main problems of health data quality management.
A comparative study by Mutale27 focused on improving HIS for decision making in five sub-Saharan African countries, namely Ghana, Mozambique, Rwanda, Tanzania and Zambia, connected with one another through the Population Health Implementation and Training (PHIT) Partnerships to enhance district health systems. The study described, compared and contrasted the PHIT approaches from these five countries to strengthen HIS and encourage the use of data in decision making, focusing on the implementation strategies from the African Health Initiative.
In general, an academic review on health systems in LMIC28 revealed that the strengthening of the health systems in LMIC is a long-term evolutionary process. There is no single blueprint for a perfect health care system,28 as health care systems are complex social systems.29 A stronger evidence base that contributes to cross-country learning is required to strengthen the health care systems in LMIC.28
While some of the above reviews have considered issues relevant to electronic HIE, none was specifically focused on barriers and facilitators to HIE. Keeping in view the research gaps, limitations and future directions mentioned in the previous reviews, a new systematic review is required on a broader scale, which encompasses all the relevant domains of barriers and facilitators to HIE in LMIC.
Research question
What are the barriers and facilitators to the implementation and adoption of electronic HIE in LMIC?