JMIR Publications

ABSTRACT

Background:

Digital health has been a tool of transformation for the delivery of healthcare services globally. An electronic health record (EHR) system can solve the bottlenecks of paper documentation in health service delivery if it is successfully implemented, but poor implementation can lead to a waste of resources. The study of EHR systems implementation in low- and middle-income countries (LMICs) is of particular interest to health stakeholders such as policymakers, funding agencies and care providers due to the efficiencies and evidence base that could result from the appropriate evaluation of such systems.

Objective:

We aimed to develop a theory of change (ToC) for the implementation of EHR for maternal and child health (MCH) delivery in LMICs. ToC is an outcomes-based approach that starts with the long-term goals and works backwards to the inputs and mediating components required to achieve those goals for complex programmes.

Methods:

We used the ToC approach for the whole implementation’s lifecycle to guide the pilot study and identify the preconditions needed to realize the study’s long-term goal in Festac Primary Health Centre (PHC), Lagos, Nigeria. To evaluate the maturity of the implementation, we adapted previously defined success factors to supplement the ToC approach.

Results:

The initial ToC map showed that the long-term goal was an improved service delivery in primary care with the introduction of EHR. The revised ToC revealed that the long-term change was the improved MCH service delivery in Festac PHC using EHR. We proposed a generic ToC map that LMIC implementers can use to introduce an optimized EHR with the assumptions about sustainability and other relevant factors. The critical success factors were sustainability: sustained improvements included trained healthcare professionals, changed mindsets from using paper systems towards digital health transformation, and using the project’s laptops for aggregate data collection for DHIS2-based national health information management system; financial: we secured funding to procure IT equipment including servers, laptops and networking but the initial cost of implementation was high, and funds mainly came from the funding partner; and organizational: the health professionals, especially the head of nursing and health information officers (HIOs), showed significant commitment to adopting the EHR system, but certain physicians and midwives were unwilling to use the EHR initially until they were persuaded or incentivized by the management.

Conclusions:

This contribution shows that ToC is a rewarding approach in framing dialogue with stakeholders and serves as a framework for planning, evaluation, learning and reflection. We hypothesized that any future health IT implementation in primary care could adapt our ToC approach to their contexts with necessary modifications based on inherent characteristics.