Adedeji Taiwo, Fraser Hamish, Scott Philip
School of Computing, University of Portsmouth, Portsmouth, United Kingdom.
Brown Center for Biomedical Informatics, Brown University, Providence, RI, United States.
JMIR Med Inform. 2022 Aug 11;10(8):e33491. doi: 10.2196/33491.
Digital health has been a tool of transformation for the delivery of health care services globally. An electronic health record (EHR) system can solve the bottleneck 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 system implementation in low- and middle-income countries (LMICs) is of particular interest to health stakeholders such as policy makers, funders, and care providers because of the efficiencies and evidence base that could result from the appropriate evaluation of such systems.
We aimed to develop a theory of change (ToC) for the implementation of EHRs for maternal and child health care delivery in LMICs. The ToC is an outcomes-based approach that starts with the long-term goals and works backward to the inputs and mediating components required to achieve these goals for complex programs.
We used the ToC approach for the whole implementation's life cycle to guide the pilot study and identify the preconditions needed to realize the study's long-term goal at Festac Primary Health Centre in Lagos, Nigeria. To evaluate the maturity of the implementation, we adapted previously defined success factors to supplement the ToC approach.
The initial ToC map showed that the long-term goal was an improved service delivery in primary care with the introduction of EHRs. The revised ToC revealed that the long-term change was the improved maternal and child health care delivery at Festac Primary Health Center using EHRs. We proposed a generic ToC map that implementers in LMICs can use to introduce an optimized EHR system, with assumptions about sustainability and other relevant factors. The outcomes from the critical success factors were sustainability: the sustained improvements included trained health care professionals, a change in mindset from using paper systems toward digital health transformation, and using the project's laptops to collect aggregate data for the District Health Information System 2-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, showed significant commitment to adopting the EHR system, but certain physicians and midwives were unwilling to use the EHR system initially until they were persuaded or incentivized by the management.
This study shows that the ToC is a rewarding approach to 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.
数字健康已成为全球医疗服务提供转型的工具。电子健康记录（EHR）系统若能成功实施，可解决医疗服务纸质文档的瓶颈问题，但实施不佳可能导致资源浪费。由于对这类系统进行适当评估可能带来的效率提升和证据基础，中低收入国家（LMICs）电子健康记录系统实施的研究尤其受到政策制定者、资助者和医疗服务提供者等卫生利益相关者的关注。
我们旨在为中低收入国家孕产妇和儿童医疗服务中电子健康记录的实施制定一个变革理论（ToC）。变革理论是一种基于结果的方法，从长期目标出发，逆向推导实现这些复杂项目目标所需的投入和中介要素。
我们在整个实施生命周期中使用变革理论方法来指导试点研究，并确定在尼日利亚拉各斯费斯塔克初级卫生中心实现研究长期目标所需的前提条件。为评估实施的成熟度，我们采用先前定义的成功因素来补充变革理论方法。
最初的变革理论图显示，长期目标是通过引入电子健康记录改善初级保健服务的提供。修订后的变革理论表明，长期变化是费斯塔克初级卫生中心使用电子健康记录改善了孕产妇和儿童医疗服务的提供。我们提出了一个通用的变革理论图，中低收入国家的实施者可用于引入优化的电子健康记录系统，并对可持续性和其他相关因素进行了假设。关键成功因素的结果包括：可持续性方面，持续改进包括培训医护人员、从使用纸质系统到数字健康转型的思维转变，以及使用项目笔记本电脑为基于地区卫生信息系统2的国家卫生信息管理系统收集汇总数据；财务方面，我们获得了采购IT设备（包括服务器、笔记本电脑和网络设备）的资金，但初始实施成本高昂，资金主要来自资助伙伴；组织方面，卫生专业人员，尤其是护理主管和卫生信息官员，对采用电子健康记录系统表现出了显著的积极性，但某些医生和助产士最初不愿意使用电子健康记录系统，直到管理层说服或激励他们。
本研究表明，变革理论是与利益相关者构建对话的一种有益方法，可作为规划、评估、学习和反思的框架。我们假设，未来初级保健中任何卫生信息技术的实施都可根据自身固有特点对我们的变革理论方法进行必要修改后应用于其具体情况。
