Implementing Electronic Health Records in Primary Care Using the Theory of Change: A Nigerian Case Study (Preprint)

BACKGROUND Digital health has been a tool of transformation for the delivery of healthcare services globally. An electronic health record (EHR) system can solve the bottlenecks of paper documentation in health service delivery if it is successfully implemented, but poor implementation can lead to a waste of resources. The study of EHR systems implementation in low- and middle-income countries (LMICs) is of particular interest to health stakeholders such as policymakers, funding agencies and care providers due to the efficiencies and evidence base that could result from the appropriate evaluation of such systems. OBJECTIVE We aimed to develop a theory of change (ToC) to assess the feasibility of EHR implementation for the delivery of maternal and child health (MCH) in LMICs. ToC is an outcomes-based approach that starts with the long-term goals and works backwards to the inputs and mediating components required to achieve those goals for complex programmes. METHODS We used the ToC approach to guide the pilot study and identify the preconditions needed to realize the study’s long-term goal in Festac Primary Health Centre (PHC), Lagos, Nigeria. To evaluate the maturity of the implementation, we adapted previously defined success factors to supplement the ToC approach. RESULTS We developed three ToC maps, which showed that the long-term change was the improved MCH service delivery in Festac PHC with the introduction of EHR. The EHR adoption and usage data from the system go-live revealed that the number of registered patients and patient registration forms completed on the EHR system was 1790. Antenatal care (ANC) and immunization encounter forms (n=198 and n=309) were completed. Vital signs (n=325) and visit notes (n=177) were entered into the EHR. We proposed a generic ToC map that LMIC implementers can use to introduce an optimized EHR with the assumptions about sustainability and other relevant factors. The critical success factors were the sustainability, financial and organizational categories. CONCLUSIONS This contribution shows that ToC is a rewarding approach in framing dialogue with stakeholders and serves as a framework for planning, evaluation, learning and reflection. We hypothesized that any future health IT implementation in primary care could adapt our ToC approach to their contexts with necessary modifications based on inherent characteristics.