title: Barriers to using eHealth data for clinical performance feedback in Malawi: A case study.
abstract: BACKGROUND
  Sub-optimal performance of healthcare providers in low-income countries is a critical and persistent global problem. The use of electronic health information technology (eHealth) in these settings is creating large-scale opportunities to automate performance measurement and provision of feedback to individual healthcare providers, to support clinical learning and behavior change. An electronic medical record system (EMR) deployed in 66 antiretroviral therapy clinics in Malawi collects data that supervisors use to provide quarterly, clinic-level performance feedback. Understanding barriers to provision of eHealth-based performance feedback for individual healthcare providers in this setting could present a relatively low-cost opportunity to significantly improve the quality of care.
  
  
  OBJECTIVE
  The aims of this study were to identify and describe barriers to using EMR data for individualized audit and feedback for healthcare providers in Malawi and to consider how to design technology to overcome these barriers.
  
  
  METHODS
  We conducted a qualitative study using interviews, observations, and informant feedback in eight public hospitals in Malawi where an EMR system is used. We interviewed 32 healthcare providers and conducted seven hours of observation of system use.
  
  
  RESULTS
  We identified four key barriers to the use of EMR data for clinical performance feedback: provider rotations, disruptions to care processes, user acceptance of eHealth, and performance indicator lifespan. Each of these factors varied across sites and affected the quality of EMR data that could be used for the purpose of generating performance feedback for individual healthcare providers.
  
  
  CONCLUSIONS
  Using routinely collected eHealth data to generate individualized performance feedback shows potential at large-scale for improving clinical performance in low-resource settings. However, technology used for this purpose must accommodate ongoing changes in barriers to eHealth data use. Understanding the clinical setting as a complex adaptive system (CAS) may enable designers of technology to effectively model change processes to mitigate these barriers.
authors.affiliation: Center for Health Informatics for the Underserved, Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Zach
authors.initials: Z
authors.lastname: Landis-Lewis
authors.affiliation: Baobab Health Trust, Lilongwe, Malawi.
authors.forename: Ronald
authors.initials: R
authors.lastname: Manjomo
authors.affiliation: Baobab Health Trust, Lilongwe, Malawi.
authors.forename: Oliver J
authors.initials: OJ
authors.lastname: Gadabu
authors.affiliation: Google, New York, NY, USA.
authors.forename: Matthew
authors.initials: M
authors.lastname: Kam
authors.affiliation: The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland.
authors.forename: Bertha N
authors.initials: BN
authors.lastname: Simwaka
authors.affiliation: Center for Health Equity Research and Promotion, VA Medical Center, Pittsburgh, PA, USA.
authors.forename: Susan L
authors.initials: SL
authors.lastname: Zickmund
authors.affiliation: Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi.
authors.forename: Frank
authors.initials: F
authors.lastname: Chimbwandira
authors.affiliation: Center for Health Informatics for the Underserved, Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Gerald P
authors.initials: GP
authors.lastname: Douglas
authors.affiliation: Center for Health Informatics for the Underserved, Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA. Electronic address: zjl1@pitt.edu.
authors.forename: Rebecca S
authors.initials: RS
authors.lastname: Jacobson
mesh_terms: D001291:Attitude of Health Personnel; D001292:Attitude to Computers; D016022:Case-Control Studies; D003197:Computer Literacy / Q000706:statistics & numerical data*; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D008295:Malawi; D062527:Meaningful Use / Q000706:statistics & numerical data*; D020380:Needs Assessment; D014600:Utilization Review
keywords: Audit and feedback; Clinical guideline implementation; Data quality; Electronic medical records; Low-resource settings; eHealth