Time Utilization Among Immunization Clinics Using an Electronic Immunization Registry (Part 2): Time and Motion Study of Modified User Workflows

Dolan, Samantha B.; Wittenauer, Rachel; Njoroge, Anne; Onyango, Penina; Owiso, George; Shearer, Jessica; Lober, William B.; Liu, Shan; Puttkammer, Nancy; Rabinowitz, Peter

doi:10.2196/39777

Cited by 3 publications

(1 citation statement)

References 27 publications

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“…After the successful pilot phase in 20 facilities of Gem subcounty, the EIR was implemented in all 161 immunizing clinics in Siaya County between 2018 and 2019. This study is part of a comprehensive evaluation of the implementation of an EIR in Siaya County, including a baseline usability study and time-in-motion study [ 18 , 19 ].…”

Section: Introductionmentioning

confidence: 99%

Usability and Acceptability of Electronic Immunization Registry Data Entry Workflows From the Health Care Worker Perspective in Siaya, Kenya (Part 3): Pre-Post Study

Wittenauer¹,

Dolan²,

Njoroge³

et al. 2023

JMIR Form Res

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Background Digital health tools such as electronic immunization registries (EIRs) have the potential to improve patient care and alleviate the challenges that arise from the use of paper-based clinic records for reporting. To address some of these challenges, the Kenya Ministry of Health and the International Training and Education Center for Health Kenya implemented an EIR system in 161 immunizing clinics in Siaya County between 2018 and 2019. The successful implementation of digital health tools depends on many factors, one of which is alignment between the technology and the context in which it is used. One important aspect of that implementation context is the perceptions of the health care workers (HCWs) using the EIR. Objective This study aimed to evaluate HCWs’ perceptions of the usability and acceptability of multiple clinic workflows using the new EIR. Methods We performed a mixed methods pre-post study using semistructured interviews with HCWs at 6 facilities in Siaya County, Kenya. We interviewed HCWs at each facility 4 times: at baseline and once after the implementation of 3 different workflow modifications (n=24 interviews). The baseline state was dual data entry with paper records and the EIR. We then implemented 3 workflow modifications for 1 full day each: fully paperless data entry, preparation of an appointment diary before patient visits for the day, and a combination of the 2 workflows. We compared ratings and themes across interviews after each of the 4 workflows to understand the changes in the usability and acceptability of the EIR. Results HCWs considered the EIR clinic workflows to be usable and acceptable. Of the modified workflows, HCWs perceived the fully paperless workflow most favorably. In all workflows, HCWs’ perceived benefits included ease of clinical decision-making using the EIR, reduced mental burden of data entry when using the EIR, and ease of identification of errors. Perceived barriers to the workflow included contextual challenges such as staffing shortages and lack of network connectivity, EIR platform challenges such as errors in saving records and missing fields, and workflow challenges such as the dual data entry burden of using paper and digital tools simultaneously. Conclusions Fully paperless EIR implementation shows great promise from a workflow acceptability standpoint, contingent upon the presence of supporting contextual clinic factors and the resolution of system performance and design challenges. Rather than trying to identify a singular best workflow, future efforts should provide adequate flexibility for HCWs to implement the new system in their unique clinic context. Future EIR implementation stands to benefit from continued monitoring of EIR adoption acceptability during implementation, both for Siaya’s program and for other efforts around the globe, as digital health interventions become more widely used.

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Section: Introductionmentioning

confidence: 99%

Usability and Acceptability of Electronic Immunization Registry Data Entry Workflows From the Health Care Worker Perspective in Siaya, Kenya (Part 3): Pre-Post Study

Wittenauer¹,

Dolan²,

Njoroge³

et al. 2023

JMIR Form Res

Self Cite

View full text Add to dashboard Cite

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Integration of a Digital Health Intervention Into Immunization Clinic Workflows in Kenya: Qualitative, Realist Evaluation of Technology Usability

Dolan¹,

Wittenauer²,

Shearer³

et al. 2023

JMIR Form Res

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Background In an effort to increase vaccination coverage in low-resource settings, digital tools have been introduced to better track immunization records, improve data management practices, and provide improved access to vaccination coverage data for decision-making. Despite the potential of these electronic systems to improve the provision of health services, few digital health interventions have been institutionalized at scale in low- and middle-income countries. Objective In this paper, we aimed to describe how health care workers in Kenya had integrated an electronic immunization registry into their immunization clinic workflows and to use these findings to inform the development of a refined program theory on the registry’s usability. Methods Informed by realist methodology, we developed a program theory to explain usability of the electronic immunization registry. We designed a qualitative study based on our theory to describe the barriers and facilitators influencing data entry and use. Qualitative data were collected through semistructured interviews with users and workflow observations of immunization clinic sessions. Our findings were summarized by context-mechanism-outcome relationships formed after analyzing our key themes across interviews and workflow observations. Using these relationships, we were able to identify common rules for future implementers. Results Across the 12 facilities included in our study, 19 health care workers were interviewed, and 58 workflow sessions were observed. The common rules developed from our qualitative findings are as follows: rule 1—ensure that the users complete training to build familiarity with the system, understand the value of the system and data, and know where to find support; rule 2—confirm that the system captures all data needed for users to provide routine health care services and is easy to navigate; rule 3—identify work-arounds for poor network, system performance, and too few staff or resources; and rule 4—make users aware of expected changes to their workflow, and how these changes might differ over time and by facility size or number of patients. Upon study completion, we revised the program theory to reflect the importance of the goals and workflows of electronic immunization registries aligning with reality. Conclusions We created a deeper understanding of the underlying mechanisms for usability of the registry. We found that the electronic immunization registry had high acceptability among users; however, there were numerous barriers to using the system, even under ideal conditions, causing a misalignment between the system and the reality of the users’ workflows and their environment. Human-centered design and human-factors methods can assist during pilot stages to better align systems with users’ needs and again after scale-up to ensure that interventions are suitable for all user settings.

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The costs of digital health interventions to improve immunization and data in low- and middle- income countries: a multi-country study (Preprint)

Federici,

Verykiou,

Cavazza

et al. 2024

Preprint

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BACKGROUND Digital health interventions, such as electronic immunization registries (eIR) and electronic Logistic Management Information Systems (eLMIS), have the potential to significantly improve immunization data management and vaccine logistics in low- and middle-income countries (LMICs). Despite their growing adoption, there is limited evidence on the financial and economic costs associated with their implementation compared to traditional paper-based systems. OBJECTIVE We aimed to measure the costs of implementing and maintaining eIR and eLMIS systems in LMICs, and to estimate the affordability of their implementation as compared to the previous paper-based registries. METHODS The study was conducted across four countries: Guinea, Honduras, Rwanda, and Tanzania. A combination of primary and secondary data sources was used for the analysis. Expenditure information regarding the design, development and implementation of the tools was directly obtained from implementers and National Immunization Program offices in all countries. Primary survey data was collected to gauge the operational expenses of immunization information systems, both with and without electronic tools using an Activity Based Costing approach. The cost of immunization information system to the national level was then extrapolated and compared to national spending on immunization as a measure for affordability. RESULTS The total costs of designing, developing and deploying eIR and/or eLMIS were I$ 1.7, 5.4, 4.7 and 33 million in Guinea, Honduras, Rwanda and Tanzania respectively. Design costs were greatly affected by the degree of customization of the tool, whereas roll out costs were mostly driven by the costs of purchasing hardware and training of health workers. Overall, the implementation of the electronic systems was associated with higher costs in Honduras (I$ 535 per facility, 95% CI 441; 702) and Rwanda (I$ 278, 95%CI 75; 482), a cost reduction in Tanzania (I$ -1,770, 95%CI -2,990; -550) and no significant cost difference in Guinea. The percentage weight of the cost of managing data with the electronic systems over the total national immunization budgets was estimated at 8.6%, 1.1%, 3.7% and 1.8% for Honduras, Rwanda, Tanzania and Guinea, respectively CONCLUSIONS Digital health interventions such as eIR and eLMIS can potentially reduce costs and improve the efficiency of immunization data management and vaccine logistics in LMICs. However, the extent of cost savings is contingent upon the degree to which these digital systems replace traditional paper-based methods. Our study suggests that the economic impact of digital health solutions greatly depends on factors such as infrastructure, implementation, and the extent to which these technologies are integrated into existing healthcare systems. Careful planning and investment are essential to realizing the full economic potential of digital health in LMICs.

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Time Utilization Among Immunization Clinics Using an Electronic Immunization Registry (Part 2): Time and Motion Study of Modified User Workflows

Cited by 3 publications

References 27 publications

Usability and Acceptability of Electronic Immunization Registry Data Entry Workflows From the Health Care Worker Perspective in Siaya, Kenya (Part 3): Pre-Post Study

Usability and Acceptability of Electronic Immunization Registry Data Entry Workflows From the Health Care Worker Perspective in Siaya, Kenya (Part 3): Pre-Post Study

Integration of a Digital Health Intervention Into Immunization Clinic Workflows in Kenya: Qualitative, Realist Evaluation of Technology Usability

The costs of digital health interventions to improve immunization and data in low- and middle- income countries: a multi-country study (Preprint)

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