Transitioning from paper to digital vaccination records: integration into clinic workflows, time utilization following workflow modifications, and impact on the timeliness of vaccinations

Abstract

Digital health interventions (DHI) have the potential to improve the management and utilization of health information to optimize healthcare worker performance and provision of care. Especially in Africa, where 25% of children remain un- or under-immunized, technologies that can help identify children due for a vaccination are particularly important for improving vaccination coverage. Low- and middle-income countries (LMICs) are beginning to introduce electronic immunization registries (EIRs) into their routine immunization services to better capture and store childhood vaccination information. Despite the increased introduction of EIRs in LMICs, few have been institutionalized at scale or evaluated to understand their impact on health systems and health-related outcomes. An improved understanding of the usability and effectiveness of these systems is needed to inform strategies for developing, deploying, and sustaining EIRs. We used qualitative data from semi-structured interviews with healthcare workers, time-and-motion observations of user workflows, and EIR data to study the effects of introducing an EIR on healthcare workers and vaccination-outcomes. The specific dissertation aims included: 1) describing the integration of an EIR into immunization clinic workflows in Kenya using realist methodology; 2) comparing time utilization of modified user workflows among immunization clinics in Kenya using an EIR; and, 3) assessing changes in on-time vaccination following the introduction of an EIR in Tanzania. We found that although EIRs were well accepted by users, there was often misalignment in goals and workflows between the system and reality which created challenges to EIR-use, increasing the time spent on data management activities, and ultimately, reducing the quality of EIR records, making them inadequate for measuring health-related outcomes at the population-level. Our research provided evidence on the importance of designing and deploying EIRs that closely align with user-workflows to increase the potential added value of these systems for improving provision of healthcare services and immunization coverage.