Dasari Mohini, Garbett Marcelo, Miller Elizabeth, Machaín Gustavo M, Puyana Juan Carlos
Division of Trauma and General Surgery, University of Pittsburgh, F1263.3, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
Department of Surgery, School of Medicine, Universidad Nacional de Asuncion, Asuncion, Paraguay.
World J Surg. 2016 Dec;40(12):2840-2846. doi: 10.1007/s00268-016-3654-3.
While the benefits of using electronic health records (EHRs) in both developed and low- and middle-income countries are known, the barriers to implementing EHRs in lower-middle-income countries have not been fully characterized. We assessed organizational readiness for implementation of a mobile (tablet-based) EHR, to create a real-time electronic surgical registry, in a busy lower-middle-income country hospital.
Six semi-structured focus groups were conducted with hospital administrators, faculty surgeons, surgical residents, interns, nurses and medical students in a large urban hospital in Asuncion, Paraguay. Focus groups were conducted over the course of three weeks during the pre-implementation phase to identify barriers to implementation. Focus group data were coded using the Theoretical Domains Framework (TDF), which are 12 validated domains related to behavior change.
Reinforcement, environmental context/resources and roles/responsibilities were the most relevant TDF domains that emerged. Residents and students were more uncertain than faculty and department heads about who would enforce the use of the tool in place of paper charting. Internet quality was a concern raised by all. The local, normative hierarchical structure within the surgical department, including piecemeal communication between the department heads and the residents about roles and responsibilities, was a major perceived barrier to implementation.
Uncertainties about reinforcement, roles and responsibilities for using a novel EHR tool, and technology infrastructure are potential barriers to address in the pre-implementation phase of introducing an EHR to a lower-middle-income country surgical service. Addressing these potential barriers with all stakeholders prior to implementation will be a critical next step in this effort.
虽然在发达国家以及低收入和中等收入国家使用电子健康记录（EHR）的益处已为人所知，但在中低收入国家实施电子健康记录的障碍尚未得到充分描述。我们评估了在一个繁忙的中低收入国家医院实施移动（基于平板电脑的）电子健康记录以创建实时电子手术登记册的组织准备情况。
在巴拉圭亚松森市的一家大型城市医院，与医院管理人员、外科教员、外科住院医师、实习生、护士和医学生进行了六个半结构化焦点小组访谈。在实施前阶段的三周内进行焦点小组访谈，以确定实施障碍。焦点小组数据使用理论领域框架（TDF）进行编码，该框架由与行为改变相关的12个经过验证的领域组成。
强化、环境背景/资源以及角色/职责是出现的最相关的TDF领域。住院医师和学生比教员和科室主任更不确定谁将强制使用该工具来取代纸质图表记录。所有人都对网络质量表示担忧。外科部门内部的地方规范等级结构，包括科室主任与住院医师之间关于角色和职责的零散沟通，是实施过程中一个主要的感知障碍。
在向中低收入国家的外科服务引入电子健康记录的实施前阶段，关于强化、使用新型电子健康记录工具的角色和职责以及技术基础设施的不确定性是需要解决的潜在障碍。在实施前与所有利益相关者解决这些潜在障碍将是这项工作的关键下一步。
