Challenges of the Integrated Information System (SINA) in Maternity Care

doi:10.21203/rs.3.rs-2202087/v1

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Challenges of the Integrated Information System (SINA) in Maternity Care

https://doi.org/10.21203/rs.3.rs-2202087/v1

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Background & Aims: The electronic health record software of Mashhad University of Medical Sciences is the Integrated Information system, called “SINA” which was launched in 2016 to enhance public health and manage mother and child information. This study aimed to identify the challenges of “SINA” focusing on the information management of pregnant women from the healthcare midwives’ perspective.

Methods: This qualitative study was conducted on 14 healthcare midwives currently working in the health centers affiliated with Mashhad University of Medical Sciences who were selected through purposeful sampling. Data were collected through in-depthand semi-structured interviews. Data analysis was carried out through thematic content analysis.

Results: The main theme challenges identified from the analyzed data were system management problems and software systems problems. The four subthemes were system flow and process management, structural problems, interface, and technical problems.

Conclusion: Based on the healthcare midwives’ perspectives, Maternity care information and training of pregnant women were well documented in “SINA”. This study can advise the policymakers to succeed in the Practical applications of the “SINA” by enhancing its strong features and ability to handle its challenges.

Primary health care

Health information management

maternal care

challenge

Mothers and children are the most vulnerable members of the population, therefore, improving and maintaining the mother and child’s level of health is one of the most essential elements of health care in every country. The World Health Organization (WHO) has envisioned that, from 2015 onwards, “pregnant women and newborns should have access to quality health care throughout pregnancy, childbirth and postpartum period”, requiring a well-functioning information system, and maintenance of medical records and referral systems between levels of facilities (1). International institutions, such as the International Federation of Red Cross and Red Crescent Societies (IFRC) and WHO consider it essential to take care of pregnant mothers and provide consistent and continuous services in health care centers (2). A mother`s health before and during pregnancy affects the health of the fetus significantly; the most common conditions and care which is provided by healthcare midwives and doctors are recorded in the medical record of the pregnant mother [3).

In Iran, prenatal care practice is delivered at primary health care (PHC) centers (4). With the emergence of electronic health (5). Along with Iran`s Ministry of Health and Treatment deputy policies for the modifications of the health system infrastructure to provide high-quality and accelerated treatment processes and electronic services to the community, systems such as the integrated health system (SIB), software health information (NAB) and the integrated information system (SINA) were designed by universities of medical sciences (6). “SINA”, Mashhad University of Medical Sciences ‘electronic health record software implemented at all levels of the Health Deputy in Mashhad since June 2015 to improve the community’s health level. Presently, health care providers in all health centers affiliated with Mashhad University of Medical Sciences are instructed to register all information retrieved and all services rendered to pregnant women residing in Razavi, Khorasan Province, Iran on this online system (7).

Information on prenatal care recorded in the “SINA” includes; the mother’s demographic information, medical history (present condition, high-risk behaviors, pregnancy, and childbirth history, medical conditions, mental health screening); laboratory results (blood, urine, syphilis, and hepatitis test, AIDS and anti-rubella antibody titer), ultrasound and Pap test); physical examination (vital signs such as blood pressure, pulse, and respiration); immunization, weighing monitoring and Intensive care, if rendered(8).

A health care provider, a midwife commonly, documents the client`s above-mentioned information [8،9). Health information systems have several benefits such as reducing medical errors, but undesirable consequences such as increased documentation time, Inconsistent workflow, late response, and information inaccessibility result in inefficiency of systems (10).

Information system user’ feedback effectively improve systems usability and efficiency; Hence in various research, national Information systems were investigated from the user point of view. Hence this study has been undertaken to identify the challenges of the “SINA” regard to pregnancy information management from the perspective of the healthcare midwives.

A qualitative thematic content analysis was conducted in 2021 among healthcare midwives working in the Mashhad University of Medical Sciences’ health centers to identify the challenges of “SINA”. The healthcare midwives who used “SINA” for at least one year were included. The length and place of the interview were coordinated and all were informed.

Data were collected using in-depth and semi-structured interviews. Explaining interview purpose, each interview was initiated with a general question including; “what challenges did you face in using “SINA”?” then the flow of conversation during the interview was directed by the researcher from broader concepts to smaller ones. After two in-depth interviews, interview guide questions were finalized. During the interview, the researcher paid attention to gaining the interviewee’s trust and providing even-handed feedback. Each interview lasted 30–45 minutes and data collection continued until it reached data saturation and new opinions no longer emerged. Thematic content analysis was used to analyze the data. The researcher writes out the transcripts of the interview immediately, and the interviewers review and edit the transcripts at the end of the meeting. The researcher read the texts line by line several times to get a general understanding.

A list of main and minor concepts was developed, and then concepts with similar themes were grouped and formed into categories. The Codes determined by two researchers were compared with each other, and in cases of disagreement, after discussion and reaching a consensus, the final thematic category was determined. To increase the results’ Trustworthiness, the researcher has used the widely accepted criteria introduced by Lincon and Guba; including credibility, dependability, confirmability, and transferability (16, 17). Data collection and analysis, themes and subthemes search, defining and naming themes vetted by team members. All transcripts were re-checked after someday, the results were compared to the previous ones for the stability and coordination of the extracted concepts and themes, and the dependability of the study was confirmed. Also, for the interviews’ confirmability, two team members conducted them independently. To confirm the transferability of the study, all the steps of conducting the study were explained to the participants in detail. In this study, ethical principles and trustworthiness were observed. This study was approved by the Mashhad University of medical sciences Ethics Board. Interviewees provided both written and verbal consent to participate.

The interview was conducted with 14 healthcare midwives currently working in Health Centers affiliated with Mashhad University of Medical Sciences. All participants were females who graduated in midwifery, with an average age of 41 years. 50% of the participants have more than ten years of work experience. The challenges associated with the “SINA” in maternity care identified after thematic content analyses were classified into the following themes; “problems related to SINA management” and “problems related to software system”. System management problem’s themes include 2 sub- themes; structural and process concepts with 7 Codes while the problems regarding software systems include three sub-themes; namely information representation, lack of information, and technical concepts with 12 codes. (Table 1)

Table 1

Challenges of users in using the integrated information system (SINA) regarding prenatal care
Main Themes	Sub-Themes	Codes	Transcribed Interview
System management Problems	System flow/Process Management Problems	The multiplicity of the duties of midwives in health centers	M1: "Most of the time, the number of patients is too many for the health care provider and there is overcrowding of patients leading to a decrease in the accuracy of recording information and or failure of information recording." M6: "Midwives who work as health care workers have lots of responsibilities, which makes.... too much. The solution is to employ midwives as specialists."
		The healthcare midwives’ impotence referring pregnant/ mothers to a gynecologist or other midwives	M4: "The “SINA” collects complete and comprehensive information, but I think it will be much better if we could refer women to a gynecologist; as we refer them just to a doctor or a nutritionist. Also, I think it will be much better if the “SINA” is linked to hospitals. "
		lack of feedback on the referral system	M2: "... and the medical forms completed by a specialist after performing the procedures can’t be uploaded in the system but instead are being kept in a folder.
	Structural Problems	referrals and follow-up with paper forms despite mothers’ registration in SINA	M7: "... all the referral and feedback sheets of pregnant mothers should be removed and the referral should be done systematically and the result of the referral should be visible in the system." M8: "The referral and feedback of pregnant mothers should be changed from a paper to an electronic one"
		No national unified linking health care system and inaccessibility to mothers’ history in other places	M2: "There are several health systems in the country in which some mothers seek prenatal care for seven months in a certain province, but in the last two months of their pregnancy, they have to transfer and refer to the health center of another province or city. Midwives as health care providers will have to undergo the process of completing the patient’s record from the beginning of her pregnancy because they do not have access to the mother's records in other systems....” “Again, all actions are performed from the beginning. The mother's information is not linked to maternity hospitals, and these centers are not aware of the mother's prenatal care status and the measures that are undertaken. The health record is not linked to the experts, and the experts do not have access to the mother's information and her file."
		SINA is not linked with other parts of the health system in Iran
		Requiring time-consuming to capture a lot of information in multiple forms at once in the system	M4: "... the forms are very long and time-consuming, and if possible, the forms should be shortened so that the health-care midwives will be able to devote more time in performing care to the pregnant mother” M8: "Registering information in pregnancy registration form takes a lot of time"
Software system problems	Interface problems	Uncertainty of the standard unit/ piece of measurement in some data elements	M5: "In the nutrition evaluation section of the pregnant mother, three or more servings of vegetables, three or more servings of fruits and dairy products are considered normal and optimal; if the mother consumes an optimal amount of these servings, does the Dragon (baby) have other -food groups to consume? In my opinion, the number of servings should be considered more reasonable and lesser than what is stated in the paper form, so that its implementation would be possible and realistic."
		Lack of default context for frequently used items	M7: "... in the information registration section, all educational training should be re-entered; it is enough to have routine training listed in the system so that there is no need to register again"
		The difficulty of generating a report
		Failure to alert high-risk maternal conditions and problems	M5: "It is better to include an options menu in the system with the title “other problems in previous pregnancy”, such as the history of high blood pressure, history of hypothyroidism and hyperthyroidism, history of anemia, etc. In the mother's dashboard, it is better to identify mothers who are at high risk and the reason for being a high risk on the main page and it should be visible.
		Failure to display information based on the needs of healthcare midwives	M3: “Follow-up records of pregnant mothers who are not registered by the “SINA” are not accessible by midwives. In the distribution of supplements (government sector), the number of supplements received in previous visits was not registered in the current form, only receipts having a corresponding code can be traced. LMP, EPC, and BMI are not displayed in the diagnostics section. " M4: "To compare BMI with the previous visit, the body mass index should be uploaded instead of entering it manually." M5: "There are many items in the form that generates NO as an answer. I suggest that in taking the client’s history of previous illness, click only the most significant items that are more significant to the patient’s condition, in this way, time can be saved. Also, highlighting the patient’s specific illness on the first page of her medical record is time-saving M7: "Every midwife should see her clients individually in the mothers' dashboard, and mothers who need follow-up and whose care has been neglected should be specified.” M8: "Mothers who have a hypothyroid problem and a body mass index of obese or overweight, cannot be retrieved from the system (pregnant mothers' dashboard). The body mass index must be obtained after 25 weeks from the beginning of pregnancy by the SINA system. A box should be designed in the mother's dashboard so that mothers who need follow-up will be kept updated. The weighting chart for multiple pregnancies in the “SINA” is not up to date and the charts in the system are based on single pregnancies. Weighing chart graph: when registering the weight of the pregnant mother on the weighing box, the process should be portrayed and then press the command “register form”, and then exit. Again press “Enter” on the pregnancy form, until you see the weighing chart graph. "Mothers who have to recover from mental problems will have their records stamped with the code “Recover”, but their names still appear in the “SINA” on the list of patients that need special care.” M12: "In every pregnancy care, file information such as diabetic mother, hypothyroidism, etc. can be seen in the top box of pregnancy care"
		Information and documentation flows are according to traditional paper form
		Inability to edit some information	M12: "Information registered in the follow-up section cannot be edited" M5: "It is suggested that the recording section on follow-up for pregnant mothers should have an edit feature with a time limit"
		Lack of some data elements in the system	M1: It is possible to check the mental health of the mother who is less than 17 weeks of pregnant. M3: "Maternal mental health screening is usually not done at the beginning of pregnancy, but it is a good idea to include it at the beginning of pregnancy." M12: LMP and EDC should only be recorded in the initial prenatal care form but should be evaluated in every visit.
		Incomplete documentation of health intervention data in the system	M8: "The results of the tests and ultrasound are not enough. NF and NB cannot be fully recorded in the ultrasound report." M5: "At the bottom section of the history form, this question appears, have you been taking folic acid 3 months before pregnancy? I would like to suggest adding this option, “Are you taking folic acid at present? M7: "The results of tests and ultrasound in the system are incomplete and in many cases are unreported. Weight records in cases of twin pregnancies are incomplete."
	Technical	Lack of national infrastructure (broadband)	M1: "One of the problems is electricity disconnections, causing disruptions to prompt recording of information” M 13: "Sudden interruption in the middle of work due to internet interruption” and M14: "The Internet is constantly interrupted”
		Updating the “SINA” during working hours	M1: "Updating the “SINA” is only possible during office hours and this causes interruption of access to the system and slow information registration.”
		Network disconnecting and being slow (leading to dissatisfaction with system speed)	M2:" Most of the time, the system works slowly” M3: “Related files in the system are difficult to open” M5: “When working with the system, information is loaded slowly” M6: “The “SINA” has low speed” M10: “The system is constantly slow and unsteady” M13: “The speed of the system is not good”

Maternal health is one of the most important areas of public health worldwide due to its definite impact on society's health (10). There are challenges involved in maternal health such as incomplete or inconsistent documentation, paying less attention to counseling and referral, and failure to report important conditions such as high BP, diabetes, family violence, addiction, and mental problems. Therefore, focusing closely on proper documentation, monitoring, and retrieval of information is necessary for accurate patient care delivery with the participation of the health team (doctor, midwife, and the mother herself) (18). This study was conducted to identify the challenges of the integrated information system (SINA) regarding the information management of pregnant women from the healthcare midwives’ perspective (the main users of the system). Our study has identified two main concepts; System management problems and software system problems respectively.

According to the results, healthcare midwives agreed on the adequacy of the information elements related to pregnancy care and its good documentation in the Integrated Information System (SINA), which is in line with the results of the study for the “SIB “by Firouznia et al and Mohammadi et al (11, 13). Problems related to SINA management were identified in two areas, process and structural problems. Similarly, Colvin's study pointed out management as a problem and a challenge in the health system related to pregnant women infected with the AIDS virus (19).

One of the problems related to processes, as a sub-theme of management problem, was the insufficiency of pregnant mothers’ referral process/flow, making a gap in the continuity of care. Similarly, Jafari et al and Mselle et al have pointed out the difficulty of referring to higher levels of the center, such as referral to a specialist (12, 20). Mohammad also considered the lack of appropriate referral policies and solutions as one of the obstacles at the organizational level in examining the barriers to using maternal and child health services (21). Mselle et al have confirmed the inability to exchange information about mothers’ conditions with pregnancy complications as the main referral problem in rural and suburban hospitals (20). Harahap et al expressed the weak referral system and its monitoring, insufficient documentation, information loss, or the loss of related documents and papers were health system-related obstacles to the maternal and newborn referral system in developed countries (22).

Capturing a lot of information, insufficiency of mothers’ referrals, and follow-up, and lack of a national unified linking health care system were identified in this study. Abolghasemi et al also presented that using the traditional system and paperwork flow leads to the dissatisfaction of system users (23). Examining problems of providing pregnancy-related health information, Dalton has also pointed out the usage of paper forms and mothers’ inaccessibility to their electronic health records (24). Similarly, Jafari et al and Howard et al pointed to the unrealistic workload, multiplicity of healthcare midwives, and the time-consuming completion of documents and forms resulting in the impossibility of following up on all cases, and their frustration (12, 14). In this regard, Give et al has also pointed to the workload and the existence of many routine tasks (25). Here, the problem of mothers’ inaccessibility to maternal care records in other cities of the country was mentioned. Similarly, Jafari and Abolghasemi et al have also pointed to the lack of access to the program and information in the “SIB“system in other provinces of Iran (12, 23).

Software system problems, the most challenging ones, were classified into two sub-themes; Interface problems and technical problems. Problems related to the normal and standard unit/ piece of measurement in some data elements identified in this study were similar to Abolghasemi's study problems in the “SIB” system; hence it is necessary to feed Information Systems with high-quality and standardized health care information (23). According to a qualitative study of users’ experiences of the “SIB“system, providing a unit conversion option would improve the system (26).

In the present study, the difficulty in extracting reports from “SINA” has been pointed out. Most users described the inefficiency of reports generated by the “SIB” system in Naghibzadeh and Mohammadi’s studies (26, 13). Improving purposive reporting generation for the maternal health program in the SINA system is a necessity (11).

SINA system is not generating alerts for high-risk mothers and their important conditions which is consistent with the priorities mentioned by Naghibzadeh et al to improve the SIB system by including warnings on the need to take vital and urgent measures regarding high-risk mothers, and warnings on dangerous prescription measures (26). Also, the study pointed out that there are no default texts for frequently repeated words. Similarly, Jafari et al also pointed to unnecessary repetitions of information entry as a challenge to the “SIB “system (12).

As the information flows through SINA with paper forms, Users are dissatisfied with the manual calculation of BMI index, failure to demonstrate mothers who have postponed antenatal care visits, and show important maternal problems such as hypothyroidism or increase weight gain on the screen. Jafari et al and Abolghasemi et al reported similar problems with the user interface such as failure to aggregate data and statistics, and to send automatic reminder messages (alerts) about important visits (12, 23). Give and Pourshahrokhi et al suggested the usage of practical solutions such as sending text messages due to their cheapness and availability and phone calls to ask for feedback from service providers in the stages of the mother's referral, which leads to the improvement of the flow of information (25, 27). Texting has been considered an important and necessary tool in the provision of health and treatment services.

The incomplete documentation of delivered care, the restriction to edit information, the lack of some data elements in the SINA and were pointed out. Similarly, in Jafari's study, software problem related to the system’s content was raised as one of the most important ones; although, features such as an allowance to edit antenatal care visits through the first 24 hours and add data items (that do not exist in the system) in the visit section are among the advantages of using the SIB system (12).

Regards to the technical problems of SINA; Network disconnecting and being slow, Lack of national infrastructure (broadband), and updating the “SINA” during working hours result in user dissatisfaction. Likewise, Jafari et al pointed to the low speed, Internet outage, and common updates as problems related to the infrastructure that have raised infrastructure problems (12). Infrastructure problems are reported as one of the health system’s problems (22). Good response time and working with no interruptions were considered among the important features of the system's performance quality (23).

In this study, the challenges and shortcomings of the integrated information system (“SINA”) were evaluated. In this regard, practical solutions should be considered to improve the performance of the SINA. it is suggested to design optional input fields and menus for facilitating information entering, provide automated calculations, making the flow of information on work processes, alert performing essential care/intervention to healthcare midwives and send messages to mothers, make possible to generate a purposive report based on user needs, facilitate extracting reports, statistics and creating charts, redesign user interface pages, interlink SINA with Health Information Technology (HIS) to exchange information for the continuity of care, and eliminate paper forms and implement a functional e-referral.

Likewise, it is recommended to make the healthcare midwives’ duties reasonable in PHC centers, investigate regularly users’ and beneficiaries’ viewpoints about the system, create a pregnancy proforma (summary of the pregnancy conditions), and strengthen the technical substructures to increase the system speed, review and compare other systems system capabilities in the country.

Acknowledgments

This article is part of a research project with a code of 981281. The authors would like to thank all the participants, especially healthcare midwives in PHC centers.

Author contributions

MM and AF designed the methodology. MM wrote the manuscript with support from AF, SsM and then EM, NR conducted the data analysis. All authors discussed the results and contributed to the final manuscript. All authors read and approved the final manuscript.

Funding

This article is part of a research project which was supported by Mashhad University of Medical Sciences (grant number of 981281). The funder had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Availability of data and materials

Although data sharing is not applicable to this article, the datasets analyzed during this study available from the corresponding author on reasonable request.

Ethics approval and consent to participate

In this study, all Interviewees were informed about the study`s objectives and they participated voluntary, and provided both written and verbal informed consent to participate. This study was approved by the Research Ethics Committee of the Mashhad University of Medical Sciences (I.D. approved: IR. MUMS. REC.1398.291) and conducted in accordance with the ethical guidelines of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing Interests

The authors declared no conflicts of interest.

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No competing interests reported.

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Challenges of the Integrated Information System (SINA) in Maternity Care

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