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

Abstract

Open source Electronic Health Records (EHRs) can improve healthcare delivery in low and lower-middle income countries (LMICs). There is demand for open source EHR systems in LMICs as they are cost-effective and provide the flexibility to customise systems to meet context-specific needs. However, open source EHRs have not proliferated rapidly. Implementation barriers prevent successful adoption. Little is known about the roles of implementers in addressing these barriers. Existing research focuses predominantly on technical perspectives for open source EHR project implementation. In contrast, this scoping review identifies contextual barriers impacting the implementation of open source EHR systems for LMICs.

This scoping review aims to provide an overview of the key contextual barriers impacting the implementation of open source EHR systems for LMIC settings, and identifies areas for future research.

An interdisciplinary scoping literature review was undertaken, guided by 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 Mixed Methods Appraisal Tool (MMAT) and the Critical Appraisal Skills Programme (CASP) checklists were utilised to assess the quality of relevant studies. Data was collated, summarised, results were reported qualitatively adopting a narrative synthesis approach.

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

While open source EHRs have the potential to facilitate enhanced healthcare and encourage sustainable development in LMICs, it is vital to take into consideration the specific context in which such technologies are to be implemented within. This study revealed the key perceived barriers that impact open source EHR implementation success. Research is required to better understand the implementation process and how socio-environmental, technical, and organisational barriers can be addressed, particularly in relation to ethics and management of data protection. We hope that the review results will inform areas for future research and enhance implementation.