Barriers and Facilitators to Electronic Medical Record (EMR) Use in an Urban Slum
Why This Research Matters
With rapid urbanization creating massive urban slums worldwide, an estimated 1 billion people live in marginalized settlements with fragmented healthcare systems and minimal continuity of care. While Electronic Medical Records are promoted as solutions to improve health information management in these settings, most implementations fail to achieve long-term sustainability. Understanding why EMR systems succeed or fail in slum environments is critical for the 60% of Nairobi's population—and millions globally—who depend on slum-based healthcare.
Key Findings
- Social factors proved more challenging than technical ones: Identity management, staff training, and user incentives were bigger barriers than power outages or internet connectivity
- Multiple identity management emerged as a unique challenge: Slum residents intentionally use different names for different health visits to maintain privacy, conflicting with EMR requirements for unique identifiers
- Infrastructure problems were significant but solvable: Power outages lasting up to 12 hours and unreliable internet required parallel paper systems and offline capabilities
- Sustainability concerns dominated: Staff worried EMRs were temporary "pilot projects" without long-term commitment, undermining willingness to invest time in learning new systems
Study Overview
Researchers conducted in-depth interviews with 10 healthcare workers from two primary care clinics in Kibera that had recently implemented open-source EMR systems. The study used qualitative methods to explore staff perceptions about both benefits and challenges of EMR use, focusing on how these systems should be deployed to maximize impact in slum settings.
Key Findings in Detail
Systems Challenges: While infrastructure problems like unreliable electricity and internet were significant, clinics developed workarounds including offline data storage and backup paper systems. The bigger issue was interoperability—EMRs couldn't integrate with required HIV databases, medication ordering systems, and government reporting requirements, forcing staff to maintain multiple parallel systems.
Software Limitations: Despite potential benefits like improved data quality and easier patient tracking, missing functionality prevented full EMR adoption. Staff needed comprehensive reporting features, laboratory interfaces, and medical supply management that weren't available, forcing continued reliance on hybrid paper-electronic systems.
Social Barriers Dominated: The most significant finding was that social factors posed greater implementation challenges than technical ones. Kibera residents commonly maintain multiple health identities for different conditions or providers, directly conflicting with EMR requirements for unique patient identifiers. Staff turnover, inadequate training, and lack of leadership consistency further undermined adoption.
Sustainability Concerns: Nearly all participants questioned whether EMR initiatives would continue long-term, viewing them as externally-funded pilots rather than permanent improvements. This perception reduced staff motivation to invest in learning and optimizing the systems.
Implications for Practice
This research provides insights for organizations implementing EMR systems in resource-constrained urban environments. The findings suggest that successful EMR deployment in slums requires addressing social and organizational factors before tackling technical challenges.
The study reveals that unique patient identifiers—fundamental to EMR design—may be incompatible with community needs for health privacy in marginalized settings. Future EMR systems for urban slums must accommodate multiple identity preferences while maintaining clinical continuity.
Most importantly, the research demonstrates that sustainability planning and community engagement are more crucial than technological sophistication for successful EMR implementation in slum healthcare settings.
Abstract
Objective
Rapid urbanization has led to the growth of urban slums and increased healthcare burdens for vulnerable populations. Electronic Medical Records (EMRs) have the potential to improve continuity of care for slum residents, but their implementation is complicated by technical and non-technical limitations. This study sought practical insights about facilitators and barriers to EMR implementation in urban slum environments.
Method
Descriptive qualitative method was used to explore staff perceptions about a recent open-source EMR deployment in two primary care clinics in Kibera, Nairobi. Participants were interviewed using open-ended, semi-structured questions. Content analysis was used when exploring transcribed data.
Results
Three major themes – systems, software, and social considerations – emerged from content analysis, with sustainability concerns prevailing. Although participants reported many systems (e.g., power, network, Internet, hardware, interoperability) and software (e.g., data integrity, confidentiality, function) challenges, social factors (e.g., identity management, training, use incentives) appeared the most important impediments to sustainability.
Conclusions
This study exposes front-line experiences with opportunities and shortcomings of EMR implementations in urban slum primary care clinics. Although the promise is great, there are a number of unique system, software and social challenges that EMR advocates should address before expecting sustainable EMR use in resource-constrained settings.