Planning for GoT-HoMIS implementation
Preliminary preparations for EMR implementation, including readiness assessment and thorough engagement of prospective users on various activities during the planning phase and actual system implementation, were necessary for effective and sustainable adoption and implementation of ICT systems [4, 19, 21].
Findings from this study have shown that the GoT-HoMIS adoption approach at the hospital was top-down, whereby the central government mandated the initial decision to acquire the system. The approach facilitated early adoption and wide installation of computer networks due to the pressure allied to the directives. However, this limited the initial preparations and involvement of end-users. The approach resulted in the introduction of the system without a thorough readiness assessment of the contextual, system and user’s specific factors existing at the facility that could have informed the implementation process.
The findings further showed that the same has also resulted in limited engagement of management and healthcare providers in the decision-making process and effective planning for its implementation. This led to incomplete implementation and partial use of the system at the hospital due to a slight sense of ownership among implementers.
Similarly, another study reported a lack of organisational readiness assessment as the source of weakness in changing system implementation [22]. These findings also corroborate studies showing that low engagement of system end-users in the design and planning of system implementation affects the system's performance [16, 23, 24].
Users experience with GoT-HoMIS use at the hospital
Enablers of GoT-HoMIS implementation
Organisational arrangements and support for the implemented system, availability of technical infrastructure for the implemented system and functionalities of the implemented system were considered important conditions for implementing an EMR [25]. The present study showed that the hospital had adopted the use of a LAN connection (the system installed locally), which was recommended as the best option in remote settings where internet reliability cannot be assured [26]. LAN is installed in about 85% of the whole hospital, thus easing the scale-up of system use to other hospital units with the availability of more computers. The study also found the hospital was connected to the national grid, whose reliability, like in most parts of Tanzania, was unlikely and, most of the time, unpredictable; thus, a generator was installed to ensure a constant supply of electricity to support system use. The availability of reliable power reduced the challenge of data losses and interruption of services associated with a disruption in power supply. Unlike other implementers' experiences, these findings were inconsistent with the experience of the system implemented in primary healthcare facilities in the slums of Kibera in Kenya, where Internet connectivity and power interruptions were reported as among the significant negative experiences for users of EMR [27].
Users' perception of the system's usefulness strongly predicted their attitudes towards and actual use of the system [28]. This study showed that most respondents had shown perceptions of the benefits likely to be achieved using the GoT-HoMIS. This was predictive of attitude towards constant use of the system among users at the study facility when computer access, training access and management support to users are enhanced, as shown in a study by Yehusalahat et al. in Ethiopia [29].
This study also found the availability of ICT technical support at the hospital among the facilitators of implementing GoT-HoMIS. The availability of a full-time ICT officer and links for external technical support were essential to enable regular maintenance of the ICT infrastructure and system and provide timely technical support to system users.
Despite the availability of ICT officers and technical support, the findings also hinted that the level of support was still not certain due to the lack of an ICT unit at the hospital with well-trained staff on the implemented systems [16]. An adequate number of ICT officers was imperative to ensure constant availability of technical support in cases of emergency and leave of absence of the available one. Again, training the ICT officers on advanced concepts of the implemented GoT-HoMIS was also important to increase their competency in maintaining the system and supporting system users. These findings were consistent with those from other studies, which showed the need for adequate technical expertise on ICT, employed systems, and accessibility of technical assistance to users as among the significant facilitators towards implementing systems [23, 30, 31].
Organisational hindrances to the system implementation
Organisational factors such as organisational structures, top management support, leadership style, system users’ training, financial resources availability, and implementation policies were considered important in influencing the effective implementation of EMR systems [24, 26]. The findings from this study have shown that the implementation of GoT-HoMIS in the hospital was partial in that only a few sections of the hospital were using the system. Despite being partially implemented, the utilisation in some departments, such as OPD, was also incomplete. Only a few consulting rooms used the system, while others still used the paper system. This partial implementation of the system two years after its inception may result from insufficient organisational assessment and planning during the pre-implementation phase. This may have impacted the system utilisation by disrupting the flow of communication among health workers in various hospital units. These findings are consistent with the study by Tilahun et al. in Ethiopia that showed partial departmental use of an EMR system contributes to a higher degree of dissatisfaction among system users [32]. The findings were also consistent with another study in a zonal hospital in northern Tanzania, showing a suboptimal use of an EMR that resulted from its partial implementation [16].
Adequate and regular training on ICT and specific EMR systems was important to facilitate using these technologies [26]. The findings from this study showed that the system users were inadequately trained in using the employed system at the hospital. To develop the capacity for mastery of the employed system, users needed to be capacitated to acquire general ICT knowledge and specific knowledge on how to use the system. The particular knowledge on the use of the implemented system needed to be tailored to the specific roles of each user on the system. Similarly, other studies reported the impact of partial ICT training of users and the need for institutional arrangements for training and re-training users for effective EMR use [31, 33]. The findings were also consistent with findings by Betuel et al. that showed a low level of training among users, with most of them organised when systems were taken into use [9]. Pre-implementation training of users and re-orientation many times a year were essential to update and maintain the knowledge and skills of users of health ICT systems.
Implementation policies and guidelines were among the most important tools both systems’ implementers and users required. They helped implementers comprehend the minimum standards and specifications necessary for the implemented system to function correctly. They also helped implementers understand the minimum desired functionalities for an EMR system, implementation process, monitoring and evaluation of the employed system, and help create a shared understanding among the users [4, 19, 21, 34]. The findings from this study showed the unavailability of guidelines for system use; thus, users mainly relied on instructions from supervisors and personal experiences. These findings were consistent with Gesulga et al., who found the lack of EMR policy and guiding documents among the primary barriers to EMR implementation that needed immediate action [35]. Another study at a hospital found the lack of facility EMR policies and standards among the causes of failure of an implemented system [16]. The availability of guidelines and standard operating procedures on the use of the system was of immense importance in the primary healthcare facilities settings where most of the users were naïve of computers and other ICT applications before use at the facility and where ICT technical support was limited. This could provide them with the tools to lean on when confronted with challenges along their daily interactions with the system and create uniformity in the use. Therefore, management of the implementing facilities needed to communicate with the system developers to ensure the availability of the relevant guiding documents, including user manuals.
On-going supervision and mentorship of system users was another important management support required to improve the competency of system users [26], especially in the facilities adopting EMR systems for the first time. The findings from this study showed low management support for supervising and mentoring system users. The supervisions were irregular, perceived as non-focused, specifically not directed at assessing the implementation context to see the bottlenecks surrounding the users and collaboratively helping find solutions. Supervisory roles were mainly left to the ICT officer, likely due to the lower level of ICT knowledge and low understanding of the employed system among other management teams. This created a poor system management capacity at the hospital. Capacity building for management teams before introducing new systems and ongoing training to update them on system developments was vital. This was thought to be a cost-effective way to improve the inter-organizational capacity to train, supervise, mentor, monitor and evaluate the system's performance. The findings from this study were in keeping with what Msiska [15] and Gesulga [36] noted: the lack of management or administrative support through supervision negatively affects the use of EMRs by users, and the implementing organisations need to develop core capacities to overcome this barrier.
The top management commitment through the involvement of end-users from idea inception to implementation of the system and through inspiring, motivating and empowering users were important to create a shared vision for the EMR system [35]. This could improve system users’ buy-in, reduce resistance, and enhance system ownership [8]. The findings from this study showed that the facility management was lowly involved in spearheading the use of the system at the hospital as well as responding to users’ concerns. Management support at scanning for the system and mobilising and prioritising resources for GoT-HoMIS implementation has been progressively inadequate since the system's inception. The top-down approach in adopting this system influences the organisational leadership and support of the implemented system. The limited use of a participatory approach that involved core users in the choices and decisions on system design and development has been found in many studies to contribute to a lack of buy-in and support of the system during implementation [16, 24]. These findings were consistent with the study by Jawhari et al. that showed the lack of timely management response to post-implementation challenges as among the main barriers to EMR implementation in the primary healthcare setting [27].
This study found that many hospital sections used both paper and electronic forms of keeping medical records despite adopting the GoT-HoMIS. Also, the hospital still uses the MTUHA paper-based registers. The registers were still considered to be the primary source of reliable information. In addition, the Ministry of Health still enforced the use of the registers in the documentation of service delivery in all primary and secondary healthcare facilities in the country. Using dual systems to keep medical records increases the work burden on healthcare workers. It burns out among staff in settings where workloads are high, resulting in dissatisfaction among users and a tendency towards system avoidance [32]. It was thus paramount to ensure the implementation of EMRs in all service delivery points in health facilities and the integration of systems to minimise the use of dual systems.
Technical hindrances to the system implementation
ICT infrastructure, such as computers, networks, software, and reliable electricity, including backup generators and uninterrupted power supplies, were critical in support of EMR implementation [4]. This study found a significant shortage of ICT infrastructure in the hospital. The computers were critically inadequate in almost all hospital sections, including service delivery points and the administration offices. This resulted in a slow flow of patients and client complaints due to prolonged waiting hours. Shortage of ICT infrastructures in the hospital crippled GoT-HoMIS implementation and the realisation of its expected benefits in improving the quality of healthcare delivery. These findings were consistent with other studies in tertiary [16] and primary care [27] health facilities in East Africa, which found shortage and poor ICT infrastructure barriers to EMR implementations. Therefore, improving computer availability and enhancing other ICT infrastructures were crucial for successful EMR implementation [23, 31].
The study also found that users were concerned about the implemented system's instability. The implemented system was incomplete and required regular updating to accommodate the raised components proposed by various users during its use. Similar findings were reported in Kenya, where users expressed dissatisfaction with the implemented system due to its lack of necessary software needed by staff to suit their EMR needs [27]. The findings also showed the concerns from some users on system instability expressed as failures to find some components that might not be directly linked to the system. This might have been due to the low knowledge, skills and experience in using the system and the need for more regular training and support.
The inability to retrieve the data required to generate the reports was another technical barrier experienced by users during their daily interaction with GoT-HoMIS. This was one of the contributing factors that demotivated the users from using the system, as they perceived it as less helpful. These findings were inconsistent with findings by Jawhari et al. in primary healthcare facilities in Kenya that found EMR to be better at accessing and searching health information and generating reports [27]. These findings were more observed as concerns from users in hospital departments with partial use of the system where the MTUHA registers were the primary source of major reports. Data retrieval failure might be due to individual skills rather than a system deficit since the experience differed in hospital units such as the medical records and hospital cash room where the system was mandated.
Individual hindrances to the system implementation
Knowledge and skills in ICT and implemented systems were critical enablers for users to utilise the system. They stimulate self-efficacy among users and excitement to use the system [37]. The knowledge and skills of ICT among users were influenced by the individual ICT background and level of organisational support on training sessions, the type of training provided to the users [25] and the complexity of the employed system. The low ICT knowledge and skills among all system users, including managers, corresponds to the hospital's low investment in training system users. These findings were consistent with the conclusion from a study that reported low skills in using ICT among barriers to EMR use and, hence, the need for more technical support and ongoing training [30]. These findings were also consistent with findings from a preliminary evaluation of various systems implemented in secondary and tertiary health facilities in Tanzania, which found dissatisfaction with system use among some users due to low knowledge and skills in ICT [9]. Therefore, the need for regular training and adequate ICT support through a well-established ICT unit within the organisation was of immense importance for the successful implementation of the system.
This study also revealed the lack of confidence among users in using GoT-HoMIS and the reluctance of clinicians and pharmacists towards using it in their daily work to provide health care services. The lack of confidence was noted among both managers and health workers. The lack of confidence is attributed to the low involvement at the beginning and low knowledge and skills in general ICT and the implemented system. The reluctance of healthcare workers was also contributed to by inadequate infrastructure and insufficient leadership and management support in implementing the system. These findings were consistent with Furusa et al.'s finding that healthcare workers tend to resist change due to fear of considerable changes in work processes, procedures, and interactions that might be brought about with the introduction of EMRs [14]. Therefore, the involvement of users throughout all the stages of EMR adoption, enhancement of ICT infrastructures, adequate and frequent training to users and management support was essential to overcome the users’ resistance.
Limitations of the study
This study examined GoT-HoMIS from the perspective of an EMR project implemented by the hospital. It only involved a few participants through qualitative inquiry; its findings cannot be generalised. However, they can be transferred to help improve facilities in similar contexts. A multi-facility, mixed-method study might generate diverse findings that might help to inform EMR implementation at large.