Implementing Electronic Health Records in Primary Care Using the Theory of Change: Nigerian Case Study

Abstract

Background 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. Objective 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. Methods 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. Results 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. Conclusions 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.

Computer Skills and Electronic Health Records (EHRs) in a State Tertiary Hospital in Southwest Nigeria

“…Some institutions committed to implementing an EHR system financially no matter how small its use may be, hence the need for effective use to prevent a waste of resources. Sustainability of the system is imperative and may be ensured through the training of healthcare professionals, a change of attitude, and the right mindset on the part of end-users [ 26 ].…”

Revolutionizing decision support: a systematic literature review of contextual implementation models for electronic health records systems

“…Of the 20 included studies,1 theory of change (Adedeji et al. , 2022), 2 were a randomized controlled trial (Moja et al.…”

“…Study design. Of the 20 included studies,1 theory of change (Adedeji et al, 2022), 2 were a randomized controlled trial (Moja et al, 2016a, b), 2 were Mixed-methods (Gold et al, 2019;Zhai et al, 2022),3 Case study (Bossen et al, 2013;Cresswell et al, 2012;Grenha Teixeira et al, 2019) and 10 were cross-sectional studies (Ahmed et al, 2020;Bashiri et al, 2023;Erlirianto et al, 2015;Iqbal et al, 2013;Jain et al, 2022;Kroth et al, 2019;Lee et al, 2022;Maillet et al, 2015;€ Ozkara et al, 2021;Sheehan et al, 2013). Location of studies.…”

“…ToC offers a framework for identifying the actions or interventions that must be taken to realize the desired results of decision support in EHRs. Adedeji et al (2022) employed the ToC approach to guide the pilot study at Festac Primary Health Centre in Lagos, Nigeria, and to determine the requirements required to achieve the project's long-term goal. The study suggested a general ToC map with assumptions about sustainability and other relevant factors that implementers in LMICs may utilize to implement an effective EHRS.…”

BEHeDaS: A Blockchain Electronic Health Data System for Secure Medical Records Exchange

“…It also covers a range of activities, including patient information processing, storage, transmission and traceability management, and security via the confidential handling of protected health information. Thus, will improves patient trust, healthcare expert collaboration, traceability, and care quality [89]- [91].…”