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

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 showed that using WhatsApp or improvising existing health information systems (HIS) improved efficiency and productivity of healthcare practitioners (HCPs) referral activities. Additionally, HCPs reported positive outcomes related to continual professional development in the given settings.The findings further show a relationship between design-reality gaps and improvisations enacted by HCPs.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.