The strategies to enable, and challenges faced with implementation of quality electronic health records in South Africa

Abstract

Background: As many middle-income countries move towards universal health coverage, the expansion of health care services using public funds has become more common. Electronic health records (EHRs) are critical for monitoring provider performance, enabling strategic purchasing and guiding the allocation of health care funds. South Africa, in its pursuit of the national health insurance (NHI), envisions EHRs as essential for informing purchasing decisions and tracking health outcomes. Despite the country’s policy efforts, the progress in implementation of EHRs has been slow. Primary aim: To examine the implementation challenges and identify potential strategies to ensure high quality EHRs in South Africa. Methods: Data were collected between 2021 and 2023 using qualitative methods. At first, in- depth interviews were conducted with 18 key stakeholders, including academics, private sector managers, and government officials, to explore the barriers and facilitators of EHR implementation in South Africa. Secondly, 38 interviews were conducted with managers, implementers, and end-users to investigate the stalling of an electronic health record system, using the Consolidated Framework for Implementation Research (CFIR). Lastly, through a rapid review of global evidence examined 41 studies on EHR implementation to identify effective end- user engagement strategies for EHR adoption in healthcare settings, guided by the Normalization Process Theory (NPT). Thematic analysis was applied in all data sets. Findings: Results revealed that while South Africa has a favorable policy landscape, the capacity and resources for a national EHR implementation, efforts have been hindered by leadership gaps, limited technical expertise, and insufficient investment in necessary infrastructure. However, the Western Cape, a province of South Africa, demonstrated significant progress, having developed a functioning EHR system through efforts spanning over two decades. A case study of a piloted EHR system further revealed some of the factors and complexities of implementation in South Africa. In this case, while the system initially showed promise, supported by strong stakeholder engagement and consultative development, it eventually stalled due to external factors such as changes in developers, funding cuts and lack of provincial support. xi Moreover, political interference in key appointments led to corruption and mismanagement of funds, further highlighting how contextual and systemic barriers can undermine a well-designed and adopted system. Lastly, the review also identified effective user engagement strategies for successful user adoption, which include early user involvement, tailored training, and continuous technical support. Moreover, the successful adoption of EHRs is best achieved when engagement strategies aligned with NPT principles of coherence, cognitive participation, collective action, and reflexive monitoring. These principles guide implementers in ensuring that users understand the purpose of the system, actively engage in learning how to use it, collaborate and continuously contribute to improving it. Conclusion: This study identified the multifaceted barriers and facilitators shaping implementation of EHRs in South Africa. The findings emphasize the need for balancing between top-down and bottom-up approaches through integrating strong policy leadership with meaningful stakeholder engagement to navigate contextual and systemic challenges. Together, a top-down approach provides centralized and strategic direction with resource allocation while bottom-up fosters user engagement which promotes adaptability and local ownership. To advance EHR implementation, it is essential to address leadership gaps, investing in infrastructure, creating a pathway for system interoperability and adopting user centered design principles are critical steps to achieving a robust national electronic health record system, a key pillar in realizing Suth Africa’s vision for national health insurance.