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Centre for Healthcare Modelling and Informatics, University of Portsmouth, Portsmouth, UK Adesina.Iluyemi@port.ac.uk Jim.Briggs@port.ac.uk Tineke.Fitch@port.ac.uk Abstract: The World Health Organisation (WHO) in 2004 called for the use of electronic health record (EHR) systems for the scaling of HIV/AIDS management and other care process for maternal and child diseases, tuberculosis (TB) and malaria management in Africa. The management of these diseases are three of the United Nations' Millennium Development Goals (MDGs). The use of EHR as a means of building the capacity of health workers and the integration of EHR with the legacy national health management information system (HMIS) was proposed as a way of building a holistic information system. To achieve this, the provision of internet connectivity and computers in different health settings was recommended. Community Based Health Workers (CBHWs), as important actors in the provision of essential primary healthcare in developing countries, require access to their patients’ medical records in order to provide quality and effective health care. Therefore, the distribution of EHR with mobile/wireless information and communication technologies (ICTs) system could provide a means of providing remote and located access to “semi mobile” CBHWs. The operationalisation of health service delivery in developing countries is through the district health system a hierarchical and distributed service and information organisation. The monitoring and regulation of this organisation is through the district health management information system (DHMIS) that provides a platform for the collection, aggregation and presentation of population data and individual patient's data records. The use of mobile technologies as a means of extending organisational support to this group of health workers for the support of their daily activities has been recently proposed by the WHO and this paper will build on this proposition. Therefore, the aim of this paper is to explore and present the end-users and organisational issues of mobile/wireless EHR implementation and adoption. A case study of a failed implementation and use of mobile EHR from a developing country will be employed to explore and understand these issues. A major finding of this paper is the need to carry out pre-implementation evaluation before the introduction of integrated mobile EHR with CBHWs in developing countries. This approach is found relevant based on the lessons learnt from the failed and other succeeding mobile EHR programmes from developing countries. Keywords: Integrated mobile EHR, developing countries, end-users & organisational issues, IS implementation and use, community based health workers, legacy health information systems 1. Introduction The World Health Organisation (WHO) (2004) in a meeting of health professional stakeholders called for the use of electronic health record (EHR) systems for the management of HIV/AIDS, maternal and child diseases, tuberculosis (TB) and malaria care processes in Africa (WHO 2004). These Millennium Development Goals (MDGs) related diseases (UN 2000) have become a kind of a “cannon fodder” for beating the nearly “dead horse” of the health systems in developing countries. These MDG-related diseases, together with the rising rate of chronic diseases such as diabetes and cardiovascular disorder (CVD), create a double burden to the fragile health systems for most developing countries especially those of the African countries (WHO 2006a). As an outcome of the meeting (WHO 2004), a case was made for the collection of patients’ records for their monitoring and management as well as for intra and inter-organisational management at health facility, sub-national and national levels. Furthermore, the use of EHR was proposed as a platform for the integration of vertical primary healthcare programmes with standalone information systems (IS(s)). Another recommendation from the meeting was the rationality of adopting open source EHR systems based on the potential of using them for building local medical informatics. The WHO group also recommended the integration of EHR with the legacy national health management information system (HMIS) as way of building a holistic information system. In order to achieve this integration, the provision of internet connectivity and computers in different health settings was suggested. The timely achievement of the MDGs by the year 2015 is a major focus of much national, regional and international financial and development attention (Agénor et al. 2006). However, there have been issues raised on the lack of appropriate data to manage, monitor and measure progress of the various
aggregation and analysis of patient-centric health data for evidence based health policy formulation and for prompt and agile health system response to patient status and epidemiological changes (Chaulagai et al. CBHWs as carers at the community level of health system will require access to the integrated EHR for holistic healthcare provision (WHO 2007). This identified gap will need to be filled with a suitable IS that is flexible and easily accessible to the health workers at the community level of the health system where most of the health needs are concentrated (Byrne and Sahay 2003). This will followed by a brief overview of HMIS in developing countries. To make a case for the provision of access to the integrated EHR for community based health workers for knowledge based healthcare 3. trained and work within the urban and rural communities in which they live (Friedman 2003). the achievement of this proposition will need to note the important human and organisational issues in the use and implementation of mobile EHR in the context of developing countries (Graves and Reddy 2000). malaria. Using mobile/wireless ICTs will suffice in this context. However. Furthermore. maternal and childhood diseases. To make a case for the integration of EHR with the legacy district health information system 2. based on the WHO’s recommendation of harnessing these technologies to support the individual and organisational activities of CBHWs (WHO 2006a). 2. However. This makes a case for the employment of an appropriate IS tool such as EHR to meet this need. This will ensure that community based health workers (CBHWs) will be able to capture patients’ data at the point of care and also to encourage knowledge based healthcare (Sorby et al. But in order to achieve the patient-centric health care goal. appropriate EHR tools should be able to provide access and interface to health workers at the community level. communication within communities. 4. The . To make recommendations for the implementation and use of distributed and integrated mobile EHR in developing countries. TB. The CBHWs carry out organisational tasks such as home-based patient care. HIV/AIDS. The next section will introduce and discuss CBHWs and their health working structure and process. there is a need to integrate the EHR with legacy health information systems (HIS(s)). in order for a CBHW to effectively practice knowledge based healthcare. The penultimate section will shed more light on the end-users’ and organisational issues observed from the failed case study on how to implement a successful mobile EHR in developing countries and finally the conclusion. To define and present the use of EHR in developing countries and bring out their commonalities and make a case for integration with the legacy health information systems and present an overview of the wireless/mobile EHR system in developing countries.mostly vertical health programmes to address these goals (Travis et al. The rationality of involving and making health care workers to take ownership and have the right to use the information available on EHR for their organisational processes and tasks was also recommended by the WHO EHR group (WHO 2004). Community Based Health Workers in developing countries CBHWs are a variety of health workers that are selected. 2004). 2005). The rest of the paper will be divided into these sections. 3. 2006). there is a need to create a platform for the timely collection. and diagnosis and/or treatment of diseases such as pneumonia. Hence. in order to make the EHR efficient in capturing accurate patient-centric data. improving the health environment. 5. This is to ensure that an integrated HIS is available for a contextual decision making process – another major recommendation of the WHO EHR working group. The next after this will introduce the developments on EHR and mobile EHR with legacy HIS(s) in developing countries. CBHWs as “gatekeepers” of the health system in many developing countries have rights to access the EHR for patient care and should therefore participate in decision-making process for health care planning and management (RHINO 2003). This status of CBHW further reinforces the need to provide connectivity through the use of appropriate and available ICTs such as mobile/wireless networks. To explore the organisational and end-users’ issues mediating in the use and implementation of mobile EHR for community based health workers through a case study analysis. Therefore. supporting health programmes such as large scale immunizations. Then a case study of failed mobile EHR from a developing country will be presented to provide insights into issues relevant for successful implementation. Objectives The objectives of this paper are: 1.
for the management of MDG health-related diseases. a review of the literature on deploying mobile/wireless EHR in developing countries revealed few evolving and pilot programmes. al. they are built from open source and proprietary software and are mixtures of standalone and networked systems (Fraser et al. The functions of HMIS are similar to that of HIS except that the emphasis is on the use of information for planning. A review of the literature on the implementation and use of EHR in developing countries carried out by Fraser et al (2005) listed six major programmes. a HMIS for the planning and management of District Health System (DHS) activities is regarded as District HMIS (DHMIS) and it should be emphasised that the role of DHMIS is to improve the health status of the population within the health district (Odhiambo-Otieno 2005). morbidity and administrative health service data and statistics and merge it with patient records (EHR) for an integrated and holistic system (Mutemwa 2006). (2005) recommended that networking these EHRs with the legacy HISs (such as pharmacy. and are key stakeholders who deserve some attention. Health Management Information System in developing countries A health management information system (HMIS) is defined as an essential tool for strengthening planning and management of health facilities (Shaikh and Rabbani 2005) and the management of health care service delivery (Azubuike and Ehiri 1999). laboratory information systems and web-based telemedicine platforms enabled through appropriate ICT infrastructure) would have significant impact on the healthcare delivery process (Fraser et al. The review revealed that they are by CBHWs for primary healthcare management of MDG-related diseases: Cell-Life. A common finding of these cases from developing countries is that they are used at the community level of the health system. implementation and evaluation and collection of administrative and management data (Odhiambo-Otieno 2005) and for decision making and improving operational health services performance (Gladwin et. 2000). In summary. 4. The literature abounds with implementation and use of mobile EHR from developed countries within and outside the hospital settings (Grimson 2001). 2005). In the same vein. another observation is that equal share of the programmes are from Africa and South America. Therefore.importance of CBHWs to the health service delivery is underlined by the fact that they constitute about one third of the health workforce (Anand and Bärnighausen 2005). Lippeveld et al. South Africa (Cell Life 2006). The WHO World Health Report 2006 recommended the use of mobile telecommunication technologies to support CBHWs for improving health outcomes and for enabling efficient logistical supply (WHO 2006b). 2005). is defined as an aggregation of a patient's record in a health setting. It is used by health workers for disease diagnosis and documentation and coordination of therapeutic activities. Community Based Health Information Tracking System (CHITS). but very few cases from developing countries are available. Electronic Health Record in developing countries EHR. Furthermore. 5. The decentralised feature of a DHS demands that the collection of both local internal operation data (facility-based) and local external intelligence (community-based data) (Gladwin et al. Therefore. 2003). The improvement of the HIS also requires the collaboration of the data users and producers (WHO 2006b). CBHWs act as both data users and producers. 2000. 2003). Fraser et. incidence. . personal digital assistants (PDAs). The DHMIS aggregates routinely collected health information and data. al. local and wide area wireless networks (LAN & WAN) was prescribed as integral to the successful building of a distributed and yet integrated EHR. without regard to temporal and spatial context (Kjeldskov and Skov 2004). 2003). and can therefore also be termed as a Routine Health Information Management System (RHMIS). 2005). Also. but this ratio might be higher in developing countries. Philippines (Tolentino et al. WHO (2006). in making the case for the strengthening of the health system for the achievement of the MDGs. emphasized the importance of health information systems (HIS) in meeting the needs and requirements of all stakeholders (WHO 2006b). also known as electronic patient record (EPR). the use of appropriate ICTs such as mobile phones. This difficulty in providing a concise definition to HMIS has always been an operational challenge (Bodart et al. HMIS is fabricated to take in epidemiological data such as health prevalence. This definition cannot be complete without consideration for the organisation where these activities take place (Gladwin et al. RHMIS have been recommended as a cost-effective method for essential health data collection and conduction of surveys in developing countries for the performance assessment of provision of population health needs (RHINO 2003).
This revelation supports the recommendation of the WHO Working Group (WG) on EHR for developing countries (WHO 2004). The organizational unexpected outcome will further be divided into process and technical outcomes. although these are desktop based-EHRs. Philippines (Domigo 2006). Community accessible and sustainable health system (Ca:sh). Another major observation is the use of open source software (Linux) and a modular approach to the development of these mobile EHRs. To achieve this proposition. There is use of other wireless networks such as satellite WAN in Haiti (Fraser et al. This model will be divided into organizational and end-user unexpected outcomes. India (Anantraman et al.1 Process outcomes . Also. Voxiva TRACnet. the widely available wireless/mobile technologies seems to provide the most appropriate means of achieving this in the context of developing countries as evident in the above presented Mobile EHR cases. In summary. Also. Cell-Life and M-DOK. Partners in Health-Electronic Medical Record (web-based PIH-EMR). a Microsoft Pocket PC device were issued at the Primary Health Care (PHC) level of the health system (Raghavendra and Sahay 2005). the use of mobile/wireless technologies was evident: mobile phones in Cell-Life. Mobile Telehealth and Information Resource System for Community Health Workers (M-DOK). The actual implementation and use of mobile EHR with the CBHWs did not commence until some years later when in 2001. However. 2004) and WiFi (WLAN) in Malawi (Douglas 2001). 2006). which are synchronised with desktop computers. CHITS. 6.Voxixa TRACnet. The use of GPRS/3G is increasingly being used with Cell-Life (Fynn et al. Voxixa TRACnet and M-DOK. The PDA based mobile EHR is made of a software standalone system which is regularly synchronized with the legacy HMIS hosted on desktop computers at the rural health centres. all of these of mobile EHRs are wirelessly connected: e. 200 new PDAs (Compaq iPAQ). 2002) and the Mosoriot Medical Record System (MMRS). 2006). the case of a failed implementation and use of a mobile EHR system with CBHWs from India will be employed to bring to the fore the relevant end-users and organisational issues. the use of EHRs in developing countries and especially Africa is relatively strong and it is increasingly becoming standardized with the use of open source software and modular approach in their development. The exceptions to this are the PIH-EMR and Ca:sh. The mobile EHR was implemented to replace the legacy paper based system so as to overcome the time lag in translating raw health data collected from the field into knowledge for health policy formulation. Kenya (Diero et al. The programme was also originally constructed to assist the CBHWs in devoting more time to health care delivery based on a perceived expected reduction in paper work.1 Organizational unexpected outcomes 6. Case Study The project known as the Health Care (IHC) programme first had its origin in an initiative between an Indian research institute and Apple Computers in 1994 (Graves and Reddy 2000). 2002). In addition. GSM-SMS in CHITS. The CHITS programme is a desktop. This HMIS is an aggregation of other RHMIS. i. Peru (Yasin et al. there is a need to ensure that the intended migration to integrated EHR-DMHIS model in developing countries should be well implemented for the CBHWs’ use. a social or open society movement simile (Wolfe et al. The first phase of the project involved the design of an appropriate human computer interaction (HCI) with CBHWs in the rural areas (Graves and Reddy 2000). 6.1. As the WHO EHR WG (WHO 2004) also recommended that internet connectivity should be provided to integrate standalone EHR with legacy DMHIS.g. Rwanda (Donner 2004).e. PDAs in Ca:sh (Compaq iPAQ) and PIH-EMR (Palm).based EHR that employs the innovative use of PC-SMS-enabled mobile devices for sending and receiving data to and from the database. A secondary analysis of the evaluation report reveals that the following unexpected outcomes which will be presented and classified according to a purposive model. WHO 2007). the trend towards the development of mobile interface to these EHRs is emerging with the need to use wireless ICTs to provide connectivity and integration with the legacy DHMIS(s). A common organizational and end-user expected outcome was the effective and efficient management of the target population immunization programme for monitoring clients’ vaccination status and schedules so as to improve the delivery of preventive health services. This was termed as an expected organizational outcome. the programme failed to achieve the set objectives two years after its implementation. 2006. Therefore.
Hence.1. Therefore. To achieve this.1 Process issues The need to carry out prior needs assessment of the workflow and organisational processes of CBHWs could be very essential for the successful use and implementation of an integrated mobile EHR in developing countries. a human computer interaction (HCI) issue resulted in CBHWs having to enter the data on the legacy papers on the field and in turn input it to the PDAs in the health centres after each daily activity. The poor design of the HMIS database had a negative influence on the integrity of the collected health data thereby negating its expected use for knowledge based policy formulation. The low battery life of the PDAs led to frequent power failure and consequent loss of data stored on the PDAs led to the frustration of CBHWs The low processing speed of the PDAs resulted in poor information recall from the EHR. This resulted in a duplication of efforts. This was also a cause of frustration to the CBHWs Overall. the intended benefit of the mobile EHR to reduce the CBHWs’ workload was defeated because of lack of assimilation into their work flow process. attempts will be made on providing successful alternatives to the wrong steps taken in the IHC case study through a directed literature search. The designers of the system could not envisage the unforeseen effects of high health needs and demand from the patients on the use of the mobile EHR for rapid data collection at the point of care within the community by the CBHWs.2 Technical outcomes The insufficient memory (I6MB) of the PDAs was reported as incapable of handling the amount of data being collected by CBHWs. 6. However. The implementers did not pilot the mobile EHR with the CBHWs. the CBHWs complained about the poor visibility and readability of the text from the PDAs’ screen. The poor user interface design.2 End-users’ unexpected outcome The lack of adequate training provided to the CBHWs before the roll-out of the programme negatively affected the CBHWs’ use of the system for its intended purposes. technical and end-users’ issues observed from the IHC case study. Complaints were about the reflection of sunlight from the black and white screen of the PDAs. These proposed alternatives will be classified under the constructs of process. 7. the lack of prior recognition of the importance of end-users’ (human) and organizational factors resulted in the mobile EHR failure. the lack of assimilation of the mobile EHR into the CBHWs’ workflow and organisational processes led to an eventual abandonment of the integrated mobile EHR as result of unmet expected benefits. BEANISH is a group of African and European Information System researchers responsible for the design and implementation of the widely adopted District Health Information Software (DHIS) in numerous African countries. 6. Therefore. 200 PDAs were rolled out at the same time with no input whatsoever from the end-users in the design of the system The lack of adequate technical support and the absent or poor maintenance culture also contributed to the programme’s failure. The approach adopted in the CHITS mobile EHR programme where social and cultural contexts of the CBHWs’ work and organisation processes were investigated before . This summation is also observation supported by “Building Europe-Africa Network for applying IST in Health Care” (BEANISH) (BEANISH 2006). recommendations will be provided on how an integrated mobile EHR for CBHWs in developing countries. it must be understood that some of the wrong steps taken in this programme could have been avoided if it were to be implemented afresh. 7. In summary. these technical unexpected outcomes were observed to be accountable for the failure of the mobile EHR. Discussion The IHC case study has provided some valuable insight and hindsight on organisational and endusers’ factors that are relevant in the implementation and use of integrated mobile her for CBHWs in developing countries context. The CBHWs could not take ownership of the PDAs due to a fear of transferred financial responsibility in the situation of damage or theft. of the mobile EHR software. The perceived high cost of the PDAs affected the sustainability of the programme. Also.
the provision of adequate technical and maintenance support has been implicated as intrinsic to the embedment of mobile ICTs into CBHWs’ health work processes (Fitch 2006). 2007). this is in contrast to the UHIN programme that employ the use of relatively cheaper Palm devices (Satellife 2006). Domigo 2006. the UHIN programme could provide some good practice in this area. contents of this should include disclaimer and transfer of liability to the PHC organisation (Tietze et al. 2005). Perhaps. 2005).. Perhaps the problem encountered with software design could have been averted had it been Palm Operating Software PDA that was implemented as also in the Ca:sh and.2 Technical issues The recent advances in mobile technology has made available devices with memory of up to 10 times more those deployed in the IHC case study (Paton and Al-Ubaydli 2006). This relative antiquity of the IHC devices could have also accounted for the complaints of low task processing speed reported by the CBHWs. this could have precluded the problem of insufficient memory. Observation from the Uganda Health InterNetwork (UHIN) in Uganda suggests that CBHWs are willing to take ownership of their enterprise issued mobile devices if it provides professional and personal benefits (Satellife 2006). Probably. (Fraser et al. 2007). is a large scale mobile eHealth programme in Uganda. Therefore. PIH-EMR programmes (Anantraman et al. . Cell Life 2006. 2002. Another observation from the case study is the use a PocKet PC mobile device. CBHWs should be encouraged to use the mobile EHR without fear of transfered financial responsibility but should also be encouraged to share some safe-guarding responsibility. The use of mobile/wireless internet access in developing countries will be appropriate for this model (Trotter et al. 2007). The UHIN could also provide some valuable lessons in area of mobile software design as iterative and modular approach was employed in order to incorporate end-users’ views and address on technical hitches as they arise (Satellife 2006). hence. 2002). the use of low-cost mobile phones should be employed instead of relatively expensive PDAs. observation from other mobile EHR programmes from developing countries reveals that the use of Open Source EHR software widely adopted (Anantraman et al. 2005). The use of solar panels to power mobile devices as in the UHIN and TRACnet programmes provides an alternative to overcome the environmental barrier of power outage (Donner 2004). the alignment of this mismatch is considered important to end-users’ adoption of the mobile EHR for information access (Sargent et al. This approach could forestall the reported lack of lack ownership of the mobile EHR by CBHWs in IHC case study. efforts must be made to ensure that appropriate standards of data storage and interoperability are adopted (Fraser et al. The use of rechargeable battery was used in the Ca:sh project and also being used in the UHIN programme. 2002. The personalisation of a mobile device is observed to correlates to its usage (Bohn 2004). However. 2005). Fraser et al. the integration of the mobile phones within the legacy system organisational structure of the TRACnet programme was reported to be responsible for its cost-effectiveness and sustainability (Donner 2004). Hence. Yasin et al. the choice of Palm PDA could have prevented the issue of perceived high cost of sustainability as observed in the IHC case study. Also. Satellife 2006. 2002) . the innovative use of web-enabled internet connectivity could help in enhancing data integrity and in ensuring success. Africa that employs the use of GSM/GPRS ad-hoc networked PDAs to support health workers’ mobile healthcare provision (Satellife 2006). Perhaps. the use innovative design of client architecture could have permitted data to be stored on a remote server rather than on the PDA and can be accessed through an internet connection (Fraser et al.the design of the system could be a valuable lesson (Tolentino et al. The need for preimplementation evaluation could also be important to prevent the issue of poor performance of legacy HMIS database design. the design of an appropriate and contextual model for improving the use of mobile EHR should be considered during pre-implementation phase. an approach that was found to be appropriate in the Cell-Life programme due to fear of theft and robbery (Cell Life 2006). Moreover. 2004) The issue of low battery life could have also been avoided with new available power efficient devices with more powerful batteries (Paton and Al-Ubaydli 2006) bearing in mind that the IHC project was initiated in 2001. there is a need to develop a guideline or protocol regulating the use of mobile devices for mobile EHR (Iluyemi et al. the integration of mobile EHR with legacy HISs is not known to be an easy venture because of end-users’ noninvolvement and mismatch of organisational processes and information management practice (Sargent et al. This approach will also ensure that an “easy to use” mobile EHR is developed for CBHWs (Fraser et al. The UHIN. 2004) However. In addition. 2005). 7. In order to achieve the WHO’s goal (WHO 2004) of an integrated EHR. Finally. Moreover. A similar approach was adopted in the Ca:sh EHR programme (Anantraman et al.
2005) and it is also integral to the provision of updated medical knowledge for point-of-care decision making and for quality healthcare provision (Pitsillides et al.2005. it must be emphasised that prior piloting and the use of prototyping or modular approach for designing the mobile EHR with CBHWs in as in CHITS and Ca:sh programes is worthy of emulation (Anantraman et al. Tolentino et al. 2005). the precursor of the IHC case study provides probably the most documented research into HCI for CBHWs in developing countries. environmental and social challenges mediating in designing of appropriate mobile EHR for CBHWs in developing countries. 2005). Tolentino et al. as this is important to its success. The poor HCI of the PDAs reported in the IHC case study could have also been avoided with modern coloured screen devices that are reflective to sunlight and will be suitable for the outreach working of CBHWs in developing countries. 2005. Base on this premise. 2005) and also could ensures real-time access to health knowledge for CBHWs. observations from the CHITS. Finally. The evaluation of the perceptions of a group of CBHWs equipped with wirelessly connected PDA-based EHR concluded that their views on technical. Cell-Life and TRACnet mobile EHR programmes indicate that the use of the available wireless technologies could make this goal of “connectivity” achievable in developing countries (Anantraman et al. These constructs were reconceptualised by . CBHWs in the IHC case study failed to use the mobile EHR for its intended purpose because of inadequate training provided for them. The contextual and appropriate employment of an integrated mobile EHR for CBHWs in developing countries could provide a means for the timely and efficient management of MDG-health related goals. Lessons from the CHITS programme documented that the early and continuous incorporation of CBHWs capacity building strategy into the EHR implementation plan is a good practice (Tolentino et al. 2005). 2005). 2007). 2002). (2005) (Fraser et al. the original work of (Graves and Reddy 2000) on of the Apple Newton with CBHWs in India. As the technical issues were mainly responsible for the abandonment of the mobile EHR by the CBHWs in the IHC case study (Raghavendra and Sahay 2005). Moreover. Tolentino et al. 8. 2004). This study provided some valuable insights into various possible technical. al. This failed case study revealed some relevant end-users’ and organisational constructs in the implementation and use of an integrated mobile EHR with CBHWs in developing countries. The lack of a preimplementation to evaluate these contextual factors is found to be a prerequisite to the failure of a large scale mobile EHR programme in a developing country. the recognition of the critical roles of CBHWs in the successful implementation and use of integrated EHR system is a critical lesson learnt from the TRACnet and CHITS mobile EHR programmes (Donner 2004. This is not to conclude that standalone mobile EHR is not still relevant in developing countries. A resultant reduction in the implementation cost of mobile EHR from using open source software is documented in the CHITS programme (Tolentino et al. Tolentino et al. However. Of particular note.3 End-users Fraser et. Cell Life 2006. 2002. 2005) made a case for the provision of relevant training to the endusers in the use and implementation EHR. In conclusion This paper has introduced and expressed the rationality of providing access and connectivity to integrated EHR for CBHWs in developing countries. 2002. the successful implementation and use of mobile EHR by CBHWs in these environments would require the prior recognition and understanding of the relevant contextual end-users’ and organisational factors. 7. 2005) . 2007). human and organisational aspects of implementation and use of the system is very integral to its successful adoption (Sargent et al. The Ca:sh experience in addressing this kind of issue should provide valuable lessons for mobile EHR implementers in developing countries (Anantraman et al. is the likely impact the introduction of mobile EHR would have on CBHWs’ ability to carry out their primary duty of healthcare and how their relationships with the community members could be altered? These questions should be answered in the design and implementation of mobile EHR with CBHWs in developing countries (Skattør et al. WHO 2007). but that networked EHR affords the possibility of achieving the goal of integrated EHR (Fraser et al. The provision of connectivity is important to the successful integration of EHRs with legacy HISs in developing countries (Fraser et al.
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