JMIR Publications

ABSTRACT

Background:

Electronic health records (EHRs) have the potential to improve service delivery through record keeping and monitoring health outcomes. As countries move toward universal health coverage, digital health tools such as EHRs are essential for achieving this goal. However, EHR implementation in middle income countries like South Africa faces obstacles.

Objective:

This study aims to explore the reasons behind a stalled implementation of the E-tick system (an electronic version of a paper primary health care register to record services provided), using the Consolidated Framework for implementation Research (CFIR).

Methods:

Using qualitative design, in-depth interviews were conducted with 38 participants to explore their perceptions and experiences, and the factors surrounding E-ticks success and stalling. Participants included managers, stakeholders, implementers and end users from the 3 implementation clinics. Data was collected using semi-structured interview guides. Thematic and CFIR framework analysis (innovation, inner setting, individual characteristics, implementation process and outer setting) were applied.

Results:

The E-tick system was designed to improve data quality in paper health registers, addressing inaccuracies in reporting to district and provincial health departments (Innovation domain). Implementers iteratively developed the system through user input from managers and clinicians, and stakeholder engagement of software developers, funders, health managers and decision-makers from the provincial health department (individuals characteristics). Although the system was initially well adopted by end users, it stalled primarily due to outer setting factors, which included a change of developers, funding cuts, and limited support at provincial health department level due to capacity gaps, political appointments and mistrust stemming from corruption and abuse of the tender system. Moreover, resistance to leveraging lessons from locally developed small-scale systems further constrained institutional support for the E-tick.

Conclusions:

Although successful implementation of EHRs can be facilitated by strong user engagement and co-design, outer setting factors such as governance, funding and policy alignment can pose significant threats to sustainability. This underscores the importance of effective synergy between top down and bottom-up processes for successful implementation.