title: Implementation of a Hospital Electronic Surgical Registry in a Lower-Middle-Income Country.
abstract: While the benefits of using electronic health records (EHRs) in both developed and low- and middle-income countries are known, the barriers to implementing EHRs in lower-middle-income countries have not been fully characterized. We assessed organizational readiness for implementation of a mobile (tablet-based) EHR, to create a real-time electronic surgical registry, in a busy lower-middle-income country hospital.
  
  
  
  Six semi-structured focus groups were conducted with hospital administrators, faculty surgeons, surgical residents, interns, nurses and medical students in a large urban hospital in Asuncion, Paraguay. Focus groups were conducted over the course of three weeks during the pre-implementation phase to identify barriers to implementation. Focus group data were coded using the Theoretical Domains Framework (TDF), which are 12 validated domains related to behavior change.
  
  
  
  Reinforcement, environmental context/resources and roles/responsibilities were the most relevant TDF domains that emerged. Residents and students were more uncertain than faculty and department heads about who would enforce the use of the tool in place of paper charting. Internet quality was a concern raised by all. The local, normative hierarchical structure within the surgical department, including piecemeal communication between the department heads and the residents about roles and responsibilities, was a major perceived barrier to implementation.
  
  
  
  Uncertainties about reinforcement, roles and responsibilities for using a novel EHR tool, and technology infrastructure are potential barriers to address in the pre-implementation phase of introducing an EHR to a lower-middle-income country surgical service. Addressing these potential barriers with all stakeholders prior to implementation will be a critical next step in this effort.
authors.affiliation: Division of Trauma and General Surgery, University of Pittsburgh, F1263.3, 200 Lothrop Street, Pittsburgh, PA, 15213, USA. mod13@pitt.edu.
authors.forename: Mohini
authors.initials: M
authors.lastname: Dasari
authors.affiliation: Department of Surgery, School of Medicine, Universidad Nacional de Asuncion, Asuncion, Paraguay.
authors.forename: Marcelo
authors.initials: M
authors.lastname: Garbett
authors.affiliation: Division of Adolescent and Young Adult Medicine, University of Pittsburgh, 3420 Fifth Avenue, Pittsburgh, PA, 15213, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Miller
authors.affiliation: Department of Surgery, School of Medicine, Universidad Nacional de Asuncion, Asuncion, Paraguay.
authors.forename: Gustavo M
authors.initials: GM
authors.lastname: Machaín
authors.affiliation: Division of Trauma and General Surgery, University of Pittsburgh, F1263.3, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Puyana
mesh_terms: D002983:Clinical Competence; D003906:Developing Countries; D057286:Electronic Health Records / Q000458:organization & administration*; D017144:Focus Groups; D006801:Humans; D007182:Income; D012042:Registries; D013503:Surgery Department, Hospital / Q000458:organization & administration*