End user experiences of an electronic health records platform in a tertiary hospital system in Kenya

Anmol Shrestha; Jasmit Shah; Zamanali Khakhar; Armando Ruiz; Zohray Talib; Sayed K. Ali

doi:10.1371/journal.pone.0332249

Peer Review History

Original SubmissionJune 4, 2025
30 Jul 2025 Decision Letter - Hamufare Mugauri, Editor PONE-D-25-30375END USER EXPERIENCES OF AN ELECTRONIC HEALTH RECORDS PLATFORM IN A TERTIARY HOSPITAL SYSTEM IN KENYAPLOS ONE Dear Dr. ali, 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 Sep 13 2025 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. 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Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 6. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. [Note: HTML markup is below. Please do not edit.] 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: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 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: Yes Reviewer #2: Yes ****** 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: No ****** 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: In this submission to PLOS One, the authors conducted a cross-sectional study between October 2023 and January 2024 at the Aga Khan University Hospital, Nairobi with staff involved in using the EHR system. A standardized electronic questionnaire by the authors was shared with the users and responses were captured on REDCap after obtaining consent. The majority of end users believed the EHR to be effective and appropriate to use within this specific and unique healthcare system. The authors note that specific strategies deployed by institutions were also successful in ensuring high rates of EHR usage and can be looked at as a blueprint for future EHR deployments in other sub-Saharan African healthcare systems. I find this manuscript to be of interest to healthcare researchers as well as readers of this journal. As such, I am generally supportive of publication with a few minor but essential comments. While the authors use conventional surveys, there have been prior studies using machine learning for healthcare, which should be noted: Environ. Sci. Technol. Lett. 2023, 10, 1017–1022 and Environ. Sci. Technol. 2019, 53, 13970–13980. Specifically, these prior studies have shown that advanced machine learning approaches can provide more details into the underlying mechanisms of biological activity that can complement the experiments. I am not asking the authors to carry out new machine learning calculations at all, but these prior treatments should be noted since these machine learning techniques are well known and a mature field now. Reviewer #2: Thank you for the opportunity to review this important and timely study, which examines the perceptions and satisfaction of end-users with a newly implemented electronic health record (EHR) system in a tertiary hospital system in Kenya. This work has the potential to inform EHR implementation strategies in different hospital systems and other countries with similar environment. Overall Comments • This study addresses a critical area and may serve as a valuable guide for implementing EHR systems in hospital settings, especially in regions with comparable infrastructures and constraints. • However, to enhance its relevance and applicability, the manuscript should include more detailed descriptions of how the EHR system was implemented in their hospital system. Please refer to my specific suggestions in the Introduction section. Introduction • Please spell out the abbreviation "ICT" on first use. • Include more details about the EHR implementation strategy. For instance: o What types of experts were included on the ICT team? o What were the specific roles of clinical informatics team members? o How frequently were town halls held, in which format (online or offline), and what topics or updates were covered during these sessions? Methods • Please provide a reference for the Michigan Public Health Institute EHR End-User Survey. • A large number of statistical tests were conducted, which raises the risk of Type I error. Please apply an appropriate correction method (e.g., Bonferroni or Benjamini-Hochberg) to control for multiple comparisons. • The rationale for comparing outcomes by gender is unclear, and these findings were not discussed. I recommend removing this comparison and focusing on comparisons across different professions. Results • Please provide summary tables for EHR impact, functionality, and overall evaluation within the main text. • Clearly reference any supplementary tables when discussing results in the text. • For supplementary materials, consider separating topics into individual tables (e.g., one table for experience, another for environment, etc.). • Review number rounding throughout the manuscript. For example, 78.99% should be rounded to 79.0%, not 78.9%. Discussion • Please include potential solutions or recommendations to address physicians’ concerns—particularly regarding lower satisfaction related to productivity and administrative burden. ****** 6. 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? 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Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0332249.r001
Revision 1
8 Aug 2025 Author Response END USER EXPERIENCES OF AN ELECTRONIC HEALTH RECORDS PLATFORM IN A TERTIARY HOSPITAL SYSTEM IN KENYAPLOS ONE [PONE-D-25-30375] We thank the reviewers for pointing out the comments below and we have tried to address the comments and strengthen the manuscript. Response to Comments Overall Editor Comments Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. Response: 1. Please ensure that you have specified a) Did participants provide their written or verbal informed consent to participate in this study? b) If consent was verbal, please explain i) why written consent was not obtained, ii) how you documented participant consent, and iii) whether the ethics committees/IRB approved this consent procedure." Response: Participants provided written informed consent electronically prior to their enrollment in the study. This consent procedure, including the use of electronic consent, was reviewed and approved by the Aga Khan University, Institutional Scientific Ethics and Review Committee (AKU-ISERC). 2. In consent please state in Ethics Method section and manuscript if it is written or verbal. If consent was verbal, please explain a) why written consent was not obtained, b) how you documented participant consent, and c) whether the ethics committees/IRB approved this consent procedure. Response: Participants provided written informed consent electronically prior to their enrollment in the study. This consent procedure, including the use of electronic consent, was reviewed and approved by the Aga Khan University, Institutional Scientific Ethics and Review Committee (AKU-ISERC). 3. Please include a complete copy of PLOS’ questionnaire on inclusivity in global research in your revised manuscript. Our policy for research in this area aims to improve transparency in the reporting of research performed outside of researchers’ own country or community. The policy applies to researchers who have travelled to a different country to conduct research, research with Indigenous populations or their lands, and research on cultural artefacts. Response: We have included a copy of the PLOS’ questionnaire on inclusivity in global research. 4. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. Response: We have deleted the Ethics statement in declarations. It only now appears in the methods. 5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. Response: We have included captions at the end of the manuscript. Reviewer #1: 6. As such, I am generally supportive of publication with a few minor but essential comments. While the authors use conventional surveys, there have been prior studies using machine learning for healthcare, which should be noted: Environ. Sci. Technol. Lett. 2023, 10, 1017–1022 and Environ. Sci. Technol. 2019, 53, 13970–13980. Specifically, these prior studies have shown that advanced machine learning approaches can provide more details into the underlying mechanisms of biological activity that can complement the experiments. I am not asking the authors to carry out new machine learning calculations at all, but these prior treatments should be noted since these machine learning techniques are well known and a mature field now. Response: We thank the reviewer for their insightful comment and for highlighting the referenced studies on the use of machine learning (Environ. Sci. Technol. Lett. 2023, 10, 1017–1022 and Environ. Sci. Technol. 2019, 53, 13970–13980). We agree that machine learning is a powerful and mature tool in biomedical research and acknowledge the value it brings in elucidating biological mechanisms. However, we note that the focus of our current study is distinct, as it centers on assessing end-user experiences of an electronic health records platform in a tertiary hospital setting in Kenya. Our methodological approach, which is based on conventional surveys, is designed to capture usability, satisfaction, and contextual factors influencing EHR adoption and interaction from the perspective of frontline healthcare providers. While machine learning may offer valuable insights in other biomedical domains, particularly in bioactivity prediction and systems biology, it falls outside the immediate scope and objectives of our study. We appreciate the broader context raised by the reviewer and have included a brief note in the discussion to acknowledge the growing role of advanced analytical techniques, including machine learning, in complementary areas of health systems research. Reviewer #2: This study addresses a critical area and may serve as a valuable guide for implementing EHR systems in hospital settings, especially in regions with comparable infrastructures and constraints. Introduction 7. Please spell out the abbreviation "ICT" on first use. Include more details about the EHR implementation strategy. For instance: What types of experts were included on the ICT team? What were the specific roles of clinical informatics team members? How frequently were town halls held, in which format (online or offline), and what topics or updates were covered during these sessions? Response: We have revised the introduction and included more on the implementation strategy as suggested in the comments. Methods 8. Please provide a reference for the Michigan Public Health Institute EHR End-User Survey. Response: We have included the reference for the survey. 9. A large number of statistical tests were conducted, which raises the risk of Type I error. Please apply an appropriate correction method (e.g., Bonferroni or Benjamini-Hochberg) to control for multiple comparisons. Response: We have added the adjusted p values using Bonferroni correction. 10. The rationale for comparing outcomes by gender is unclear, and these findings were not discussed. I recommend removing this comparison and focusing on comparisons across different professions. Response: We have removed the table on gender and revised accordingly. Results 11. Please provide summary tables for EHR impact, functionality, and overall evaluation within the main text. Clearly reference any supplementary tables when discussing results in the text. For supplementary materials, consider separating topics into individual tables (e.g., one table for experience, another for environment, etc.). Response: We have revised the results and added the summary tables in the main manuscript. 12. Review number rounding throughout the manuscript. For example, 78.99% should be rounded to 79.0%, not 78.9%. Response: We have reviewed all tables and, in the percentages, we have rounded to one decimal point. Discussion 13. Please include potential solutions or recommendations to address physicians’ concerns—particularly regarding lower satisfaction related to productivity and administrative burden. Response: We have provided some recommendations in the discussion. Attachments Attachment Submitted filename: EHR PLOS ONE - Response Feedback.docx https://doi.org/10.1371/journal.pone.0332249.r002
28 Aug 2025 Decision Letter - Hamufare Mugauri, Editor END USER EXPERIENCES OF AN ELECTRONIC HEALTH RECORDS PLATFORM IN A TERTIARY HOSPITAL SYSTEM IN KENYA PONE-D-25-30375R1 Dear Dr. Sayed, 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. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Hamufare Dumisani Mugauri, Ph.D. Medicine and Health Sciences Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0332249.r003
Formally Accepted
Acceptance Letter - Hamufare Mugauri, Editor PONE-D-25-30375R1 PLOS ONE Dear Dr. ali, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr Hamufare Dumisani Mugauri Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0332249.r004

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