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

Eligibility criteria

We used the inclusion and exclusion criteria presented in table 1 to identify articles that meet the study objectives.

Information sources and search strategy

PubMed, Science Direct and IEEE Xplore were the electronic databases used for the literature search. We conducted the search using keywords based on four concepts, namely “electronic health record,” “adoption,” “quality of healthcare,” and “developing countries.” Medical subject heading (MeSH) terms were also used to supplement the keyword search in the PubMed database, hence it is a controlled vocabulary thesaurus used for indexing articles. We conducted forward and backward citation searches on significant search results and manual searches on health informatics journals found in developing countries. We presented the search strategies in table 2.

Selection process

We imported the search results from all databases and citation searches into EndNote to begin the selection process. First, we removed duplicate records. After doing so, we screened the remaining records to detect subject relevance with the research objectives considering their title and, or abstract. Next, full-text articles were identified for retrieval. Finally, articles that fulfilled the inclusion criteria were selected for qualitative analysis and synthesis. The author (WJ) validated the entire selection process to ensure its accuracy.

Data collection process, data items, analysis and synthesis

The data collection process started by identifying the main concepts in the three research questions that appear as results or findings in each of the reviewed articles. This approach formed a conceptual basis for data extraction under the corresponding heading in a Microsoft Word document. The headings include the authors’ name, publication year, research design, data collection methods, data analysis techniques, study population, sample size and sampling techniques. Moreover, the findings from each of the studies included were extracted as EHR functions, challenges, opportunities and healthcare quality indicators addressed. Content analysis was used to organise related concepts under the categories EHR in LICs, challenges of EHR adoption in LICs, opportunities of EHR in LICs and EHR and healthcare quality in LICs. Finally, narrative synthesis and ordering of the evidence were conducted in each of the four categories by comparing and contrasting with previous studies conducted on the topics.

Risk of bias

Each study included in the review was subject to an appraisal using the Joanna Briggs Institute checklists.31 32 Accordingly, we selected and included studies with an optimum score based on the requirements in the checklist. Further, to avoid selection bias, we strictly followed the protocol. In doing so, to some extent, we managed the risk of bias in selection, analysis and reporting.

Study selection

As presented in figure 1, we retrieved 109 records following the search strategy defined. We removed three records that were duplicates. Further, we excluded 66 records after reviewing titles and, or abstracts. Out of 40 studies sought for retrieval, we discarded six as a result of not finding their full text. Out of 34 studies accessed for eligibility, we included 12, which qualified for the inclusion criteria.

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Study characteristics

In this review, we used the world bank classification of 2023 to identify LICs.33 The studies selected systematically from this group were four from Ethiopia, two from Uganda and one from each remaining country: Gabon, Rwanda, Malawi, Sierra Leone, Angola and LICs altogether (Kenya, Rwanda, Uganda and Mozambique). Based on the type of study; five were quantitative, two were qualitative, three were mixed-type, one was agile software development and one was situational analysis. The details of each study are presented in table 3.

EHR in low-income countries

In this review, 9 of the 12 studies showed some of the major functions of EHR/EMR in LICs. The first one is the OpenMRS-Ebola, which was implemented in Sierra Leone. The system can track patients’ vital signs, medication, intravenous fluid ordering and monitoring, laboratory results, and clinician notes, and export data for clinical decision-making.34 EMR systems are being used to enhance tuberculosis surveillance and control in Angola.35

In Ethiopia, studies were conducted to assess the healthcare providers’ technological and organisational readiness and the level of EHR adoption. The findings indicated that the overall readiness of healthcare providers was inadequate.36 Ahmed et al37 noted that 39.8% of healthcare providers surveyed showed a score above the mean intention to use EMR in northwest Ethiopia. Whereas, a study by Oumer et al38 in eastern Ethiopia showed optimal EMR usage level. These findings portray that EHR systems are not adopted as expected to address quality healthcare in the country.

In Uganda, a locally developed EHR platform (Stre@mline) is highly accepted and used despite implementation challenges.39 The system can monitor patients, control stock levels, provide early warning and capture prescription errors. Similarly, Fraser et al40 noted that OpenMRS in Rwanda supports healthcare delivery by managing patient records, making informed decisions, and providing useful alerts and reminders. Finally, mUzima is a mobile-based EMR system that is providing quality healthcare in countries like Kenya, Rwanda, Uganda and Mozambique.41

Barriers and facilitators to EHR adoption in LICs

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 al42 identified the quality of a system, support, information, actual use, satisfaction and impact as potential barriers. Oza et al34 showed that inconsistency in EHR systems creates an enormous challenge. In addition to this argument, experience is another barrier to adopting EHR as a health professional over 5 years of experience had two times higher odds of using EMR than early career workers.38 Overall, in most LICs, EHR adoption exists in the preimplementation phase.36

Four studies identified facilitators to HER adoption in LICs, as presented in table 4. Bisrat et al43 found 70%–95% of healthcare providers have a favourable perception of using EMR systems. Similarly, Oumer et al38 identified that about 85% of healthcare professionals demonstrated goodwill in using EMR systems. Fraser et al40 noted the role of EHR systems in supporting patient care by providing alerts ahead of complications. The immaturity of health information exchange infrastructure in many LICs provides an opportunity to enhance EHR systems by incorporating mobile-based systems.41

Table 4 illustrates people and environment-related factors are both facilitating and impeding EHR adoption in LICs. While tool-related factors influence, task-related factors are facilitating EHR adoption. Overall, poor integration of EHR among the work systems factors affects EHR adoption. The absence of facilitators under tools and interaction among the four work systems indicated an insufficiency of technology and lack of management support to facilitate EHR adoption, respectively.

EHR and healthcare quality in LICs

EHR systems are improving healthcare delivery in both developing and developed countries. An empirical work reported from Rwanda,40 Uganda39 and Malawi44 showed that EHR systems improve healthcare by managing patient information, supporting informed decisions and providing useful alerts. In developed nations, EHR-based clinical trials are providing evidence about treatment strategies, patient safety, care and health policy decisions.45 Based on the WHO definition, this review considered seven quality indicators of healthcare: Safety, effectiveness, people-centredness, timeliness, efficiency, equity and integrated service.1

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.

Strengths

The review followed a protocol to select and synthesise relevant studies on the topic. Further, it identified research gaps to be addressed by future researchers. Overall, because of absence of previous systematic reviews in LICs, the findings could help develop implementation strategies and policies.

Limitations

The search result was vulnerable to various problems, such as reporting bias or lack of enough research outputs from LICs, as only studies from eight countries out of 28 were included. Additionally, a literature search was conducted only on PubMed, Science Direct, IEEE Xplore and journals of health informatics in developing countries. However, the quality of the studies was not compromised by following the review protocol.

Implications for practice, policy and future research

The review findings suggest all actors involved in EHR systems should collaborate effectively to yield a better outcome in healthcare delivery. This can be supported through EHR adoption policies, which are currently missing in many countries. Future research should focus on comparative studies on the practice of EHR systems in developing and developed countries.