User Perceptions and Use of an Enhanced Electronic Health Record in Rwanda With and Without Clinical Alerts: Cross-sectional Survey
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Abstract
Background: Electronic health records (EHRs) have been implemented in many low-resource settings but lack strong evidence for usability, use, user confidence, scalability, and sustainability. Objective: This study aimed to evaluate staff use and perceptions of an EHR widely used for HIV care in >300 health facilities in Rwanda, providing evidence on factors influencing current performance, scalability, and sustainability. Methods: A randomized, cross-sectional, structured interview survey of health center staff was designed to assess functionality, use, and attitudes toward the EHR and clinical alerts. This study used the associated randomized clinical trial study sample (56/112, 50% sites received an enhanced EHR), pulling 27 (50%) sites from each group. Free-text comments were analyzed thematically using inductive coding. Results: Of the 100 participants, 90 (90% response rate) were interviewed at 54 health centers: 44 (49%) participants were clinical and 46 (51%) were technical. The EHR top uses were to access client data easily or quickly (62/90, 69%), update patient records (56/89, 63%), create new patient records (49/88, 56%), generate various reports (38/85, 45%), and review previous records (43/89, 48%). In addition, >90% (81/90) of respondents agreed that the EHR made it easier to make informed decisions, was worth using, and has improved patient information quality. Regarding availability, (66/88) 75% said they could always or almost always count on the EHR being available, whereas (6/88) 7% said never/almost never. In intervention sites, staff were significantly more likely to update existing records (P=.04), generate summaries before (P<.001) or during visits (P=.01), and agree that “the EHR provides useful alerts, and reminders” (P<.01). Conclusions: Most users perceived the EHR as well accepted, appropriate, and effective for use in low-resource settings despite infrastructure limitation in 25% (22/88) of the sites. The implementation of EHR enhancements can improve the perceived usefulness and use of key functions. Successful scale-up and use of EHRs in small health facilities could improve clinical documentation, care, reporting, and disease surveillance in low- and middle-income countries.
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Overall, most data were considered fit for purpose, as confirmed by the user survey, which showed a reliance on the EHR data for clinical care and reporting.
“Overall, most data were considered fit for purpose, as confirmed by the user survey [4], which showed a reliance on the EHR data for clinical care and reporting.”
From Factors Influencing Data Quality in Electronic Health Record Systems in 50 Health Facilities in Rwanda and the Role of Clinical Alerts: Cross-Sectional Observational Study (2024) · cites this paper as [4]
The survey’s Results report EHR use for patient records and reporting, and over 90% of respondents agreed that it improved patient information quality. But the paper does not assess whether most data were fit for purpose, and “reliance” overstates the reported use: 42% used the EHR most of the time or more, versus 76% for paper records (Results, Use of EHR Functions; page not provided). (LLM, conf=0.86)
Experimental — accuracy not yet measuredExisting approaches for evaluating the impact of CDS on provider EHR-use activities and clinical workflow heavily rely on manual data collected through surveys, qualitative interviews, direct observation, and audio/video recording.
“Existing approaches for evaluating the impact of CDS on provider EHR-use activities and clinical workflow heavily rely on manual data collected through surveys, qualitative interviews, direct observation, and audio/video recording.10,13,16–19”
From Electronic health record activity changes around new decision support implementation: monitoring using audit logs and topic modeling (2025) · cites this paper as [17]
The Methods (The EHR Implementation Science Study; page unavailable) describe a structured-interview survey, including open-ended questions, used to assess EHR use and perceptions at sites with and without an enhanced EHR. This supports the paper as an example of manual survey and interview data collection, but it does not establish that evaluation approaches heavily rely on such data generally, or document audio/video recording or direct observation of clinical workflow. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe inclusion criteria for the 112 HFs in the larger study favored HFs with better information technology hardware and successful implementation of a server monitoring tool.
“The inclusion criteria for the 112 HFs in the larger study favored HFs with better information technology hardware and successful implementation of a server monitoring tool [4].”
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- Authors
- Fraser, H. S. F., Mugisha, M., Remera, E., Ngenzi, J. L., Richards, J., Santas, X., Naidoo, W., Seebregts, C., Condo, J., & Umubyeyi, A.
- Affiliations
- Brown University (US)
- University of Rwanda (RW)
- Ministry of Health (RW)
- Centers for Disease Control and Prevention (US)
- Jembi Health Systems (ZA)
- Corresponding author
- Fraser, Hamish S F
- ORCID
- Venue
- JMIR Medical Informatics
- Publisher
- JMIR Publications Inc.
- Published
- 2022-05-03
- Volume
- 10
- Issue
- 5
- Pages
- e32305
- ISSN
- 2291-9694 (ISSN-L)
- PMC
- PMC9115652
- OpenAlex
- W4210797585
- Cited by
- 33
- References
- 20
- Citations by year
- 2026: 6 · 2025: 12 · 2024: 7 · 2023: 7 · 2022: 1
- FWCI
- 5.06
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- JMIR Medical Informatics (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Funders
- Rockefeller Foundation
- World Health Organization
- Brown University
- University of Rwanda
- International Development Research Centre
- European Commission (2015-2017, HORIZON2020, 661289)
- Rwanda Biomedical Centre
- Centers for Disease Control and Prevention (U01GH000782)
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Nursing › Issues, ethics and legal aspects › Nursing Diagnosis and Documentation
- Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
- Keywords
- electronic health records, clinical alerts, HIV care, health information systems, EHR usability, health worker perceptions, EHR adoption, resource-limited settings, Rwanda, clinical documentation, disease surveillance, health reporting
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