Contextual Barriers to Implementing Open-Source Electronic Health Record Systems for Low and Lower-Middle Income Countries: Scoping Review

Background:

Open-source electronic health records (EHRs) can enhance healthcare delivery in low and lower-middle income countries (LMICs) by improving the collection, management and analysis of health data needed to inform healthcare delivery, policy, and planning. While open-source EHR systems are cost-effective and adaptable, they have not proliferated rapidly in LMICs. Implementation barriers slow adoption, with existing research focusing predominantly on technical issues preventing successful implementation.

Objective:

This interdisciplinary scoping review aims to provide an overview of contextual barriers affecting the adaptation and implementation of open-source EHR systems in LMIC settings, and identifies areas for future research.

Methods:

We conducted a scoping literature review following a systematic methodological framework based on Arksey and O’Malley. Seven databases were selected from three disciplines: medicine and health sciences, computing, and social sciences. The findings were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The Mixed Methods Appraisal Tool (MMAT) and the Critical Appraisal Skills Programme (CASP) checklists were utilized to assess the quality of relevant studies. Data was collated and summarised, and results were reported qualitatively, adopting a narrative synthesis approach.

Results:

The 13 studies included in this review examined open-source EHR implementation in LMICs from three perspectives: socio-environmental, technological, and organizational barriers. Key issues identified include limited funding (n=13), sustainability (n=13), organizational and management (n=11), infrastructure (n=10), data privacy and protection (n=10), and ownership (n=5). Data protection, confidentiality, ownership, and ethics emerged as important issues, often overshadowed by technical processes (n=11).

Conclusions:

While open-source EHRs have the potential to enhance healthcare delivery in LMIC settings, implementation is fraught with difficulty. This scoping review shows that depending on the adopted perspective to implementation, different implementation barriers come into view. A dominant focus on technology distracts from socio-environmental and organizational barriers impacting the proliferation of open-source EHRs. The role of local implementing organizations in addressing implementation barriers in LMIC settings remains unclear. A holistic understanding of implementers’ experiences of implementation processes could help characterize and solve implementation problems, including those related to ethics and the management of data protection. We hope that the review results will inform areas for future research and enhance implementation.