Usability and acceptability of electronic immunization registry (EIR) data-entry workflows from the healthcare worker perspective in Siaya, Kenya

Abstract

Introduction: Digital health tools such as electronic immunization registries (EIRs) have the potential to improve patient care and alleviate challenges that arise from the use of paper-based clinic records for reporting. To address some of these challenges, the Kenya Ministry of Health (MOH) and the International Training and Education Centre for Health in Kenya (I-TECH-Kenya) implemented an EIR system in all 161 of Siaya county’s immunizing clinics between 2018 – 2019. Successful implementation of digital health tools depends on many factors, one of which is alignment between the technology and the context in which it is used. One important aspect of that implementation context is the perceptions of the healthcare workers (HCWs) using the EIR. Without full adoption of the EIR by HCWs into their clinic workflow, many of the potential benefits of the EIR cannot be realized. This study evaluates HCW perceptions of usability and acceptability of multiple clinic workflows using the new EIR. Methods: We performed a mixed-methods pre-post study using semi-structured interviews of healthcare workers at 6 facilities in Gem sub-county of Siaya county, Kenya. We interviewed HCWs at each facility 4 times: at baseline and once after implementation of each of three different workflow modifications (n=24 interviews). The interviews used a combination of open-ended interview questions and scale-based indicators based on the NASA Task Load Index and usability heuristics. The baseline state involved dual data-entry with paper records and the EIR. We implemented the three workflow modifications for one full day each: fully paperless data entry, preparation of an appointment diary prior to the day’s patient visits began, and a combination of paperless plus preparation workflows together. We compared aggregate scores from the indicators and interview themes across each of the four workflows in order to understand changes in usability and acceptability of the EIR. Results: We found that, overall, the EIR clinic workflows were considered usable and acceptable by the HCWs. Of the modified workflows, we found the HCWs perceived the fully paperless workflow to be the most favorable, while the baseline, preparation, and combined workflows had mixed results. In all workflows, benefits perceived by the HCWs included ease of clinical decision-making using the EIR, reduced mental burden of the data entry when using the EIR, and ease of identification of errors. Challenges perceived by the HCWs regarding workflow acceptability included contextual challenges such as staffing shortages and lack of network connectivity, EIR platform challenges such as errors saving records and missing fields, and workflow challenges such as the dual data entry burden of paper and digital tools. Conclusion: Fully paperless EIR implementation shows great promise from a workflow acceptability standpoint, contingent upon presence of supporting contextual clinic factors and resolution of system performance and design challenges. An acceptable EIR will provide adequate flexibility for HCWs to implement the new system in their unique clinic context. Rather than trying to identify a singular best workflow, future efforts to optimize EIR implementation should look for ways to maximize flexibility, reliability of the app, and strong enabling environments, and let the HCWs in each clinic match the EIR to their real-world context to have the best results for data use.