WhatsApp as an improvisation of health information systems in Southern African public hospitals: A socio-technical perspective

Abstract

Digital health interventions, particularly electronic referrals (e-referrals) and health information systems, have revolutionised clinical workflows in public hospitals by automating processes. However, the utilization of e-referrals has yielded mixed outcomes, with varying levels of success in organisational processes. This paper explores improvisation of health information systems in Southern African public hospitals from a socio-technical perspective. In particular, the paper explains the design-reality gaps giving rise to improvisations of mandated health information systems in order to understand their occurrence and impact on referral outcomes. We employed the design-reality framework and the Process framework for Healthcare Information System Workarounds and Impacts to explain the socio-technical issues related to the phenomenon of interest. We conducted semi-interviews with 31 respondents from health organisations as case studies. Respondents from two public hospitals in South Africa and two in Namibia were interviewed to examine how they devised improvisations to various health information systems in each setting. The findings indicated that use of WhatsApp in the absence of mandated health information systems (HIS) or improvisation of existing HIS was reported to be advantageous for healthcare practitioners (HCPs), leading to improved efficiency and productivity in the execution of referral activities. Additionally, HCPs reported positive outcomes for health organisations related to continual professional development in the given settings. The findings further show a relationship between design-reality gaps and improvisations enacted by HCPs in both case studies. The observed gaps are related to poor management systems and structures, lack of HCPs’ involvement in the roll-out of HIS and inadequacies of existing HIS to support referral tasks. These study findings can be insightful and useful to system developers and other stakeholders for devising measures to address the gaps. Improvisations and use of WhatsApp for healthcare service delivery present opportunities for innovation and process improvements for health organisations.