PONE-D-21-01911

A multivariate statistical evaluation of actual use of electronic health records systems implementations in Kenya

PLOS ONE

Dear Dr. Ngugi,

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Chaisiri Angkurawaranon

Academic Editor

PLOS ONE

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3. Thank you for stating the following in the Acknowledgments Section of your manuscript:

'Authors would like to acknowledge KeEMR system developers for providing input into the testing of the study instrument (query script), and helpdesk support to study participants. We also appreciate the support by Kenya Ministry of Health, County health directors, AMPATH Plus and FACES service development partners, and County Health Records Information Officers (CHRIOs). Much appreciation also to all the healthcare facilities and the system champions for their participation in the study.'

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I read the paper with interest and I can see that there is some interesting data here. However I was not really convinced by some aspects of the work as presented here and found the paper rather too long and a bit repetitious while not really focusing on a clear set of issues and a strong message for the reader.

In the introductory section a number of older references are used to set the scene. The paper would be stronger if it focused on more recent studies in its literature review and on literature that serves the needs of this particular study e.g. that details specific metrics of system use, , assessment of system value, and the analysis of log files. Some of what was here felt a bit out-of-date (references over 10 years old). It hardly mentioned core models of system usage and success e.g. DeLone and Mclean get a very brief mention but their model – first and revised version – may be very useful to underpin this work.

I would be more interested in the data that is collected here if it was not described (on a couple of occasions) as ‘objective’ or ‘un biased’. From my position this data is useful, interesting, but it is not a higher truth than other data collected in other ways. Nor is it (or any other data) un-biased – computer systems and their data are biased from the day they are developed! I would like more discussion of the validity and potential of the data and independent variables, and how they might be interpreted or add value. But this cannot be asserted or taken for granted..

Similarly I felt that the focus on the GLM model was the weakest part of the paper. To reduce the complex reality of clinical work and use of EHR over years to a single model seems a rush to judgement. The discussion the Table 4’s findings seemed to be more description than an evaluation or analysis of the results (although the discussion section did take this a little further – e.g. page 17).

Before any such model I would suggest more attention paid to the data itself and to the various correlations that it reveals.

I was not clear what the section on ‘Implementation by county (page 11 and 12) added to the paper – just a large table . The data on implementation year is interesting but could find a home elsewhere in the paper

I was puzzled by the definition of some variables. For example, is the ‘EHR Variable completeness’ (page 13) really 100%in any meaningful way? Is the fact that then data fields are defined in the software really enough to say this? A real measure might be the number of these fields that are actually in use – e.g. populated in over x% of patient records?

I was also puzzled by the Observations measures (page 13). I would have thought this would need a denominator to of any interest – and what the denominator should be would be (patient encounters, clinical staff-users etc) is an interesting issue to address in the paper at some depth, but it only appears briefly in the discussion (page 17).

In summary I believe that the paper could be significantly improved by tightening the presentation and some of the repetition of findings, focusing on interpreting the data more and less on the GLM. I would also suggest a stronger discussion section that takes the reader further and focuses on the ‘so-what ‘. The present version seems to repeat the main findings, but not take the argument further.

Reviewer #2: Thank you for the opportunity to review this manuscript on actual use of electronic health records systems. Since the advent of electronic health records, there have been concerns about the benefits of using EHRs and the success of implementation of EHRs. In the research conducted, the authors examined seven indicators that might reflect the actual use of electronic health records.

Upon reading the manuscript, the question arises whether the authors are really identifying the actual use of EHRs by health care staff with the seven indicators they have chosen.

The first indicator is ‘staff system use’ and was measured by the percentage of facility staff members who used the EHRs during the reporting period. In their study, the authors found a low average of 18.2%. However, this number has little meaning without providing more information about the context. For instance, are the health care facilities using a few stationary computers or are they using a shared or individual iPad? With a stationary computer health care professionals often log in with one user account and subsequently use the EHRs with multiple professionals on one user account. This is also the case when working with a shared iPad. Therefore, the ‘staff system use’ as measured by the authors is not an accurate indicator for actual use of the EHRs.

In addition, another indicator is ‘standardized terminologies’. This indicator is measured through the proportion of key terminologies that are mapped to standard terminologies. Mapping of terminologies is mostly relevant for the exchange of health care information and for the use of routine care data for research purposes. However, this mapping has no direct influence on the use of EHRs by health care staff in daily care practice. So, how does this indicator say anything about the actual use of EHRs? That remains unclear in this study. Moreover, there are different standardized terminologies for doctors, nursing staff and other health care staff. The authors lack to explain by which health care staff the EHRs are being used. Therefore, the indicator standardized terminology remains vague and unclear.

Besides, the other five indicators can also be questioned whether they are an accurate indicator for actual use of the EHRs by health care staff. Therefore it is very doubtful whether the authors in this study really assessed the state of the implementations of EHRs.

The authors already mentioned themselves that the study findings are not generalizable to other countries. They suggest that their approach for analysing EHRs use can be generalizable to other countries. However as explained before, this approach seems very questionable. Therefore, the added value of this manuscript for the international research community is not clear.

More detailed comments:

- Use of abbreviations. The authors are not consistent in use of abbreviations for the electronic health records. They use both EHR, EHRs and EMRs which causes confusion. Besides, the authors use a lot of other abbreviations which is not beneficial for the readability of the manuscript. The authors should only use universally used abbreviations and only when necessary. This applies both to the body of text and the tables.

- In the ‘Introduction’ section the authors write that EHRs improve quality of care and support HIV programs at a national level. Authors should explain these suggested relations further, since it remains unclear.

- In the ‘Introduction’ section the IS success model is introduced without further describing the model. For readers who are not familiar with this model this paragraph is unclear. Further explanation is needed.

- In the ‘Material and Methods’ section the authors write there are two types of EHRs endorsed for national development. It is unclear what was meant by ‘two types’. Does this mean EHRs from two different vendors?

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Reviewer #1: Yes: Tony Cornford

Reviewer #2: No

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PONE-D-21-01911R1

A multivariate statistical evaluation of actual use of electronic health records systems implementations in Kenya

PLOS ONE

Dear Dr. Ngugi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 13 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Chaisiri Angkurawaranon

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I found this revised manuscript better in many respects,. It is tighter in its focus , less repetitious and has lost some extraneous material. I was however disappointed to see that the rebuttal letter’ was so brief and indicated so little about how the authors had chosen to revise the paper.

The way that the authors cite and use the DeLone and Mclean model is better in this version, but is still rather unimaginative. To say that the model has 6 dimensions and then only focus on one (‘system use’) is to underplay the model and the data available here. For example, is there not data on information quality here, and perhaps system quality too? Clearly this is not a ‘full’ D&M data set – but their work can be really helpful in interpreting and validating the data and analysis (more so than an add hoc GLM).

I am still confused as how the ‘Observations’ measure is to be interpreted without some denominator. As a raw value it seems to be a proxy for so many things (size, enthusiasm, patient type, resources etc. etc.) as to be of little use.

As I said in my earlier review, I am not convinced by the GLM analysis, and I am not sure that he findings here tell us very much. If the authors think otherwise then I encourage them to draw out the importance of these findings to convince me or other readers. - I note that in this version f he paper relatively little discussion is devoted to the GLM findings.

Overall, I believe that the paper does have interesting information to convey, and has potential for an analysis of this data that can make a contribution to the study of EHR in LMICs and in particular to studies of systems use. I do however suggest a further revision and edit to catch a number of small language issues and to strengthen the discussion of the data and its ability to reflect use. I would also tone down claims such as on page 18)to ‘conclusively give a true state of EHRs use’. That is a claim that no researcher across the world can make!! Equally I don’t think you can claim ‘highly reliable data’ (same page). I suggest fewer of such claims and more time addressing the subtlies of the data, set in the context. This will impress a reader far more.

Reviewer #2: Thank you for addressing the comments raised in a previous round of review and adjusting your manuscript. I believe the adjustments have strengthened the manuscript.

Yet, I have one remark left about the adjustments made regarding the indicator ‘staff system use’. It was good to read you now address the issue of sharing individual-passwords. However, you very quickly draw the conclusion that training on appropriate use of account credentials is needed for staff. Thereby you assume that a lack of knowledge is the underlying cause, yet how do you know such a lack of knowledge exists? Can you refer to studies that indicate such a lack of knowledge? Other studies often point towards problems with the user-friendliness of EHRs, instead of a lack of knowledge among staff. Therefore, I believe you should look again if you can substantiate your conclusion/recommendation.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Tony Cornford

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

A multivariate statistical evaluation of actual use of electronic health records systems implementations in Kenya

PONE-D-21-01911R2

Dear Dr. Ngugi,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Chaisiri Angkurawaranon

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: