An offline-first electronic health record for vulnerable populations: A mixed-methods feasibility study

While there is a growing body of research showing that Electronic Health Records (EHRs) can improve health outcomes in limited resourced settings, these EHRs often require continual access to an internet connection and are challenging to customize and deploy. To address these challenges, Hikma Health (HH) has designed a free, open-source and offline-first EHR for physicians providing care in low-resource settings. This paper describes a mixed-methods study to understand the feasibility of the HH EHR in two clinics that care for displaced or rural populations in Lebanon and Nicaragua. Clinic demographics and metrics were collected through REDCap and descriptive statistics were analyzed. Using a framework analysis, in-depth interviews were conducted at both sites until thematic saturation. Interviews were coded by three authors with an inter-rater reliability kappa score of 7.6. Quantitative data showed that after about three hours of training and three weeks of use, participants were comfortable using the HH EHR and the HH EHR decreased patient interview times by three minutes. Quantitative data showed that these findings were due to the ease and simplicity of the modular workflows. However, when used in settings that required syncing multiple times during a patient's encounter with different clinicians, the system faced challenges due to inconsistent network connectivity and the design of the sync functionality. The HH EHR was a feasible solution for offline-first settings. Both clinical sites observed that the implementation of the EHR enhanced documentation, decreased medical errors, and improved patient outcomes through tracking medications and diseases.