Revisiting and Extending Alter's Theory of Workarounds for Low‐Resource Environments: Insights From Electronic Medical Record Systems

Abstract

ABSTRACT The adoption of Electronic Medical Record (EMR) systems is expected to enhance efficiency, data quality, and accountability in the primary healthcare sector; yet, in low‐resource settings, the adoption is undermined by a set of practices referred to as “workarounds.” Although workarounds are common, the topic of EMR workarounds in public primary healthcare facilities in low‐ and middle‐income countries is still undertheorised. This research will address this problem by applying Alter's Theory of Workarounds to the EMR workarounds in Tanzanian public primary healthcare facilities. We conducted a qualitative multi‐case study in six public primary health facilities with diverse infrastructural capacities. Data were collected through in‐depth interviews with 41 healthcare providers and non‐participant observation and thematically analyzed using inductive coding. Our study found that EMR workarounds emerge from the interconnection between technical issues (such as system downtime and rigid system functionality), organizational issues (such as resource constraints and insufficient technical support), and human‐related factors (primarily high workload and low digital literacy). Workarounds, through parallel paper recording and selective data entry, facilitate service provision while eroding data validity, healthcare accountability, and equality. Through our analysis, we have expanded the Alter theory framework by adding context‐specific elements, including contextual vulnerability, humanitarian and administrative tensions, and the creation of workarounds that perpetuate inequality. Workarounds in this case can be seen not only as expressions of resilience but also as an indicator of vulnerability. We recommend that further research be needed to apply the extended Alter's theory framework to additional LMIC settings as well as non‐health sectors. Patient perceptions need to be examined in future studies, as they will provide important insights into the effects of the above‐mentioned factors on the quality of healthcare provision.