JMIR Publications

ABSTRACT

Background:

The implementation of Hospital Information Management Systems (HIMS) and Picture Archiving and Communication Systems (PACS) in low- and middle-income countries (LMICs) is essential for clinical modernization. However, long-term operational sustainability is systematically threatened by infrastructure volatility, hardware maintenance overhead, and post-pilot technical debt.

Objective:

This scoping review aims to map the global evidence regarding the technical maintenance lifecycles, structural configurations, and operational sustainability vectors of facility-wide health IT stacks in resource-constrained tiers.

Methods:

Adhering strictly to PRISMA-ScR consensus standards and an official protocol registered on osf.io, we executed a systematic search across PubMed/MEDLINE, Embase, Scopus, and IEEE Xplore. Data extraction was conducted via a hybrid approach combining systematic screening with a local, regular-expression-driven text-mining engine to review a total of 152 source publications, yielding 199 distinct technical and operational evaluation entries.

Results:

The comprehensive data charting pipeline mapped exactly 199 unique technical evaluation layers across the included literature. Quantitative synthesis indicated that long-term HIMS/PACS sustainability relies heavily on offline-first engineering models. Only 3.0% (n=6) of deployments sustainably utilized continuous online cloud-native architectures. The dominant operational pattern was the deployment of isolated facility local area network (LAN) fail-over topologies (52.8%, n=105) to shield point-of-care workflows from external network drops, augmented by scheduled asynchronous batch synchronization (24.1%, n=48) and store-and-forward edge queuing (16.1%, n=32). For semantic maintenance, open-source frameworks (such as the OpenMRS reference ecosystem, 20.6%, n=41) leveraging managed, integer-keyed concept dictionaries significantly minimized software technical debt compared to heavy, high-latency hierarchical ontological configurations.

Conclusions:

Digital health infrastructure longevity in LMICs is directly governed by decentralized, offline-first network topologies and pragmatic structural interoperability profiles (HL7/DICOM) that align with localized engineering capabilities. To prevent premature post-pilot degradation, future health IT implementations should transition toward an explicit Pragmatic Edge-Tier Implementation Model, prioritizing lower total cost of ownership, utilizing low-maintenance concept dictionaries over complex ontologies, and actively cultivating on-site technical capacity to manage database maintenance natively. Clinical Trial: Not applicable (Scoping Review Protocol registered prospectively on the Open Science Framework: https://osf.io/ qz2af)