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A convergence of cultures and strategies to improve Electronic Health Record implementation within a Tanzanian clinical environment Open Access


Other title
Action Research
Ethnographic case study
Change management
Resource-poor environment
Sub-Saharan Africa
Electronic Health Record
Type of item
Degree grantor
University of Alberta
Author or creator
Kitson, Nicole A
Supervisor and department
Lacy, Paige (Medicine, University of Alberta)
Lee, Shoo (Paediatrics, University of Toronto)
Examining committee member and department
Scott, Richard (Medicine, University of Calgary)
Houston, Stan (Medicine, University of Alberta)
Jardine, Cindy (Centre of Health Promotion Studies, University of Alberta)
Neville, Doreen (Associate VP Academic, Memorial University)
Chan, Kevin (Paediatrics, University of Toronto)
Department of Medicine

Date accepted
Graduation date
Doctor of Philosophy
Degree level
This research explored the question: “How can we improve the implementation of an Electronic Health Record (EHR) within a Tanzanian clinical environment?” The objectives included working with local stakeholders to identify opportunities to improve, and exploring barriers and facilitators to change. My role changed over time from facilitator to change agent, and carried with it the promise that my presence was part of the solution, and the realization that it was also part of the problem. The research is presented as an ethnographic case study. It draws from socio-technical and social interactionist theories in which information systems are understood by looking at the interrelation between the technology and its social environment. Field research occurred on site at Haydom Lutheran Hospital (HLH) in Haydom, Tanzania from March 2007 to May 2008. A two-week follow-up visit occurred in Fall 2008. HLH is a pilot site for the Care2X hospital information system. Data was collected through multiple qualitative and quantitative methods. During the field research period, EHR implementation could not be expanded beyond Outpatient Registration. Server issues were the bottleneck and had a cascading effect. These issues identified a gap in knowledge and expertise to implement changes. But the problems went deeper still to reveal issues related to trust and power. The research provides insight to guide stakeholders through EHR implementation so that they might better formulate their own plans to improve the collection and use of health information. This begins with asking the question: Is an EHR necessary? Important steps are understanding barriers and facilitators for change, the influence of organizational culture and strategy, and the importance of context as these have implications for system success and sustainability. However, these lessons are not all new. What this research does do is tease out the influence of outsiders in the clinical environment. Reliance on expatriate resources is not uncommon within low-resource environments and leads to a convergence of cultures and strategies. This research contributes to understanding the dichotomy between local and expatriate power, and is a timely contribution to existing, but limited, research studies on EHR implementation in Sub-Saharan Africa.
License granted by Nicole Kitson ( on 2011-07-19T18:13:16Z (GMT): Permission is hereby granted to the University of Alberta Libraries to reproduce single copies of this thesis and to lend or sell such copies for private, scholarly or scientific research purposes only. Where the thesis is converted to, or otherwise made available in digital form, the University of Alberta will advise potential users of the thesis of the above terms. The author reserves all other publication and other rights in association with the copyright in the thesis, and except as herein provided, neither the thesis nor any substantial portion thereof may be printed or otherwise reproduced in any material form whatsoever without the author's prior written permission.
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