JMIR Publications

ABSTRACT

Background:

Digital health interventions (DHIs) have the potential to improve the provision of healthcare services through digitized data collection and management. Low- and middle-income countries (LMICs) are beginning to introduce electronic immunization registries (EIRs) into their routine immunization services to better capture and store childhood vaccination information. Especially in Africa, where 25% of children remain un- or under-immunized, technologies that can help identify children due for a vaccination are particularly important for improving vaccination coverage. However, an improved understanding of the effectiveness of these systems is needed to develop and deploy sustainable EIRs in LMICs.

Objective:

We conducted an interventional pre-post study which sought to improve time efficiency through workflow modifications in Kenyan immunization clinics. Our aim was to describe how activity times differed after introducing workflow modifications that could potentially reduce the time needed to perform routine data entry activities. Our intent was to demonstrate changes in efficiency when moving from the existing dual-data entry workflow to a future paperless workflow by health facility size and length of experience.

Methods:

We tested how three workflow modifications would affect time utilization amongst healthcare workers using the EIR at the point-of-care compared to baseline immunization clinic workflows. Our outcome of interest was the time taken to complete each task and immunization clinic session, comparing the time between the baseline and modified workflows. We used a standardized tool to observe and document the immunization clinic workflow. To estimate differences in time utilization, we used bivariate analyses and fit multivariate linear mixed-effects models.

Results:

Our study found that for healthcare workers using an EIR, the introduction of modified workflows decreased the amount of time needed to provide services to children seen in the immunization clinic. With a baseline mean time of 10 minutes spent per child, this decreased by about 3 minutes when the preparation modification was introduced and almost 5 minutes for the paperless and combined modifications. Our initial hypothesis that there would be differences seen at baseline by size of facility and length of experience was confirmed. Results pertaining to the EIR’s performance and ability to connect to the internet were particularly insightful about potential causes of delays.

Conclusions:

We were able to conduct a fairly quick clinical simulation exercise introducing modified workflows and estimating their impact on time utilization in immunization clinics using an EIR. We found that the paperless workflow provided the largest time savings when delivering services, although this was threatened by poor EIR performance and internet connectivity. This study demonstrated that not only should DHI be built and adapted for particular use-cases, but that existing user workflows also need to adapt to new technology.