Digitalization of healthcare in low-resourced settings: Opportunities and challenges, Qualitative study in Oromia, Ethiopia

Digitalization of healthcare in low-resourced settings: Opportunities and challenges, Qualitative study in Oromia, Ethiopia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Digitalization of healthcare in low-resourced settings: Opportunities and challenges, Qualitative study in Oromia, Ethiopia Mohammed Tiya Beriso, Shimelis Assefa, Getachew Mamo, Abdunesir Wako, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7528690/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Several resource-limited countries around the world have benefited from the global advancement of technologies in various sectors, including healthcare by implementing digital solutions. One of these advancements in technology is the digitalization of healthcare through electronic medical records, which plays significant role in streamlining paper-work processes. This study aims to examine the opportunities and challenges of healthcare digitalization in low-resource settings, focusing on selected facilities in the Oromia Regional State of Ethiopia. Specifically, it explores how digital health initiatives such as electronic medical records and telemedicine affect service delivery, data management, and patient outcomes, while identifying barriers to their effective implementation. However, the adoption of digital healthcare systems in low-resource settings faces persistent challenges. These include the lack of sustainable government funding and heavy reliance on external donors, shortages of adequately trained healthcare professionals and, in some cases, resistance to adopting new technologies, the short-term and fragmented nature of many digital health initiatives, and the absence of advanced security mechanisms, particularly for remotely accessed systems that could leverage AI-based tools. Methods a qualitative approach that employed in-depth interviews and site observation in data collection from healthcare workers. MAXQDA version 2020 was used for thematic data analysis to create a pattern. Results This finding indicates that digitalization presents substantial opportunities for improving healthcare delivery in the selected facilities. The availability of supportive conditions has helped create an environment conducive to sustaining these initiatives. However, several challenges persist, many of which arise from gaps in fully realizing these opportunities and enabling conditions. Such challenges negatively influence perceived usefulness and perceived ease of use, ultimately shaping user behavior. Addressing these barriers is essential to ensuring consistent system adoption, user satisfaction, and the long-term sustainability of digital healthcare systems. Conclusions The study underscores the need for a comprehensive, the involvement of several participants to effective utilize digital health in low-resourced settings, addressing data privacy concerns and requiring robust policies. Digitalization healthcare opportunities challenges Oromia Figures Figure 1 Introduction Digitalization has played a significant role in the widespread transformation of healthcare systems worldwide ( 1 ). Many healthcare facilities in low-resource countries, whether rural or urban, were operated manually, making them difficult to access due to the immaturity of their implementation or deployment ( 2 ). This full adoption of digitalization has addressed the issue of restricted access by allowing remote patient-physician communication through telemedicine or mobile health (mHealth). With the advent of digitalization, patients were consulting their physicians remotely through telephone or video calls ( 3 ). This has helped reduce transportation costs and eliminate long wait times associated with in-person appointments, which can sometimes last for two or more days. This not saves money but also saves time for both doctors and patients. Furthermore, the integration of digital technologies has enhanced healthcare delivery in low-resource countries by decreasing the need for human labor and physical resources ( 4 ). This advancement was further realized through the adoption of Electronic Medical Records (EMRs), which enabled healthcare providers to maintain comprehensive digital documentation of patient information, including medical histories, treatment plans, and diagnostic results. Furthermore, the utilization of digital technologies in low-resource countries has allowed public health initiatives to create opportunities for raising awareness through educational campaigns even in settings with limited resources ( 5 ). To disseminate knowledge on maternal health, immunization, sanitation, and appointment scheduling, digital tools such as mobile applications, SMS, and short films are utilized ( 6 ). These tools facilitate the delivery of instructional materials directly to people’s home, even for those residing in areas with limited internet access ( 7 ). Additionally, digital platforms can facilitated the creation of virtual health communities, which allowed individuals to easily share experiences, receive peer support, and ask questions related to management of mental health issues and specific chronic illnesses ( 8 ). In the same vein, digitalization has brought significant opportunities for improving healthcare delivery ( 9 – 11 ). This is achieved by reducing overall costs through the elimination of manual administrative tasks, decreasing reliance on physical infrastructure, and minimizing the use of paper records in resource-constrained countries including the study health facilities. However, several factors have significantly hindered the progress of healthcare digitalization. First, infrastructural deficit such as a limited number of computers, the unequal distribution of smartphones, unreliable electricity, and insufficient internet connectivity that substantially impede the effective deployment and use of digital health systems effectively in low-and middle-income countries ( 12 ). Secondly, insufficient financial investment in training and incentives for both healthcare and non-healthcare personnel exacerbates implementation challenges; several eHealth system fail because of low workforce, low digital literacy, limited opportunities for professional development and a lack of adequate technical support, further hindering the ability of individuals to build competency (13). Third, the absence of formalized incentives and compensation plans for community health workers and other lay health workers contributes to lower motivation, job satisfaction, and engagement levels, and heightens attrition, which often occurs because of delayed or missing payment, undermining digital health activities (14). Finally, a persistent imbalance in the healthcare worker-to-patient ratio in resource-poor settings further constrains the scalability and sustainability of digital health programs (15–17). Additionally, the digitalization of healthcare has been implemented only in specific healthcare facilities that have access to electricity or generators, and internet, which are not always reliable(18). This led to the loss of important data feeds, and very low level of digital literacy among healthcare providers. These included insufficient training and a lack of awareness among the general population. There are significant yet undetectable challenges related to security and privacy concerns in many low-resourced countries. To address these issues (security and privacy), the relevant authorities must enforce the laws that everyone must adhere to (19).Punishments should be imposed on those who engage in cybercrimes, whether they do so anonymously or not. This is crucial for safeguarding patient data from unauthorized monitoring in low-resourced countries due to underdeveloped cyber-security infrastructure and a lack of trained personnel in this area. Another issue in our nation was the immaturity of healthcare financing. This is because not all districts and regions are included in the system and did not have agreements with healthcare institutions or hospital (20). In contrast, digital technology has the potential to help overcome these obstacles and determinants to improve healthcare outcomes in settings with limited resources (21). Despite this attempt, the selected health facilities initiated the implementation of digitalization to overcome the paper-laden and loss of patient information, which resulted in long wait times that have not yet been resolved. The researcher used in-depth interviews and site observations to collect data from participants, with the goal of qualitatively addressing this issue and uncovering hidden insights that hinder full-scale digitalization in various areas. What are the opportunities and challenges associated with the digitalization of healthcare in low-resourced settings, specifically in Oromia, Ethiopia? This study aims to identified the potential opportunities and barriers of digitalization in Oromia, Ethiopia’s healthcare system, focusing on healthcare professionals’ access and perception of digital tools’ in healthcare delivery Methods and Materials The qualitative research design with case study for in-depth analysis of the digitalization efforts is used (22). Therefore, a case study research design was employed to examine the effective utilization of digitalization efforts that improve healthcare information systems. Settings and gaining access to a community The Eastern and Western Oromia Regional States of Ethiopia are home to two tertiary healthcare facilities: Adama Specialized Hospital and Medical college (AHMC) located in Adama, and Ambo University Referral Hospital (AURH) in Ambo. Jimma University’s Institute of Technology granted the lead investigator ethical clearance and a letter of approval for data collection. He then forwarded these documents to the appropriate authorities to obtain access. Several medical professionals were scheduled for in-depth interviews to gather information on healthcare digitalization initiatives. Through this process, the researcher selected key informants from the healthcare industry who have expertise in digital health activities, including the challenges and opportunities associated with enhancing digital health practices at specific healthcare institutions in low-resource countries. Qualitative Case study Method Two healthcare facilities were selected from a total of 114 health facilities and four tertiary specialized hospitals in the region. These two facilities were chosen purposefully because they had already started the process of digitalization, unlike the other healthcare facilities in the region. Data collection methods Based on their continuous involvement in digitalization initiatives, the primary investigator selected thirty healthcare workers from both facilities. Data collectors were hired to conduct in-depth interviews using reference number (Comp/JiT/019/2015 E.C) from Jimma University, Institute of Technology. The principal investigator developed the interview tools based on our main dissertation, which is uploaded as a supplementary file in this study. However, the authors (Tiya et al., 2025) used the respondents in the forthcoming article by Sage, in addition to one respondent for this study (23). Each respondent was asked to volunteer to participate in the study. Using predetermined time limits, the authors and data collectors aimed to conduct interviews that did not exceed one hour, with in-depth interviews lasting a minimum of half an hour. To reduce researcher bias and allow respondents to express their opinions openly, impartial observers were hired to serve as interviewers during the qualitative data collection process. A total of 1740 minutes were needed to collect the data. Data gathering for Ambo University Referral Hospital (AURH) took place over one month (from November 21-December 20) in 2024, as the system did not launch until that year. In contrast, data collection for AHMC occurred over three consecutive months, like June 1-August 30, 2023. The time was adjusted to the appropriate time and date of the respondents' consent. To preserve authenticity and guarantee the anonymity of respondents’ opinions in our research data, in-depth interviews were conducted by collectors alongside the researcher’s physical observations. Lastly, the data are ready for transcription, ensuring dependability, conformability, trustworthiness and credibility, as described in the next section of this manuscript. Data Quality Control Methods To ensure the quality of the qualitative methods, the authors followed the steps outlined by (24,25). The recorded audio of respondents was listened to several times, with authors rehearsing their thoughts to transcribe them accurately without missing any details. These textual data were then reviewed by linguists, who compared them to the recorded audio to ensure trustworthiness and accuracy. Afterward, the linguists identified themes related to opportunities, challenges, and strategies to overcome them, highlighting these with appropriate codes. In this study, in-depth interviews were conducted to maintain authenticity, including all the units of data that the system could process to uncover new or hidden insights from the interviewees for further analysis aligned to the models. The Integration of the DeLone and McLean Information System Success Model (DMISSM) and Technology Acceptance Model (TAM) in the theoretical framework. Technology Acceptance Model: It is a paradigm for understanding user adoption of new technology created by Fred Davis (26). It suggests that perceived usefulness (PU) and perceived ease of use (PEOU) are key factors influencing a user's choice to use a new system. Healthcare workers' perceptions of the system's ease of use and its effectiveness in improving their daily tasks are crucial factors in determining adoption. Qualitative interviews with healthcare professionals can help investigate these perceptions and their intentions towards using the system. In inquiring about how they feel the technology helps or hinders their daily tasks and how challenging it is to use. DeLone and McLean Information Systems (IS) Success Model: It is a broader framework that evaluates the success of an information system. Unlike TAM, which focuses on individual user acceptance, this model looks at success from a multi-dimensional perspective (27–29). It proposes that the success of an Information Systems is dependent on six interconnected dimensions: The DeLone and McLean IS Success Model is a multi-dimensional framework that evaluates the success of healthcare digitalization in information system lenses. It focuses on six interconnected dimensions: System Quality, Information Quality, Service Quality, Use, User Satisfaction, and Net Benefits. System Quality refers to the technical quality of the system, including reliability, ease of use, and security. Information Quality deals with the quality of the information produced by the system, such as accuracy, timeliness, and completeness. Service Quality focuses on the quality of support provided by the Information System department or vendors. The ultimate measure of success is Net Benefits, which refers to the system's impact on individuals, organizations, and society. A qualitative study would use this model to structure interview questions and observations to understand the opportunities and challenges from each of these perspectives. Data Analysis The authors repeatedly reviewed the text data to align the themes with their corresponding codes for the analysis of observational data and in-depth interviews until they identified the intended themes. The data were subsequently imported into qualitative data analysis software, specifically MAXQDA (30). Furthermore, a pattern of developmental themes was developed via both deductive and inductive approaches. In this process, the Technology Acceptance Model (TAM) and the DeLone and McLean Information Success Model (DMISM) served as templates for deductive analysis. Finally, the researchers carefully reviewed the coded interview text to determine appropriate patterns that align or are linked to the models for the successful implementation of digitalization efforts in healthcare systems. Further details will be provided in the subsequent section of the results. Results The study revealed that inductive analysis was conducted through data-driven analysis, and focused on the acceptance of technology and the information success model of DeLone and McLean deductively. In addition to the two established models, this analysis also explored other aspects such as infrastructure, training, and policy, as moderating variables. The newly proposed theoretical model reflects the deep-rooted factors necessary in determining the acceptance and success of healthcare digitalization efforts in tertiary health facilities, facilitating them in a selected healthcare context. These factors include infrastructure issues, policies, training support, healthcare insurance status, and healthcare system outcomes or net benefits expected from holistic improvements in healthcare services. These factors were used as a guide for the newly proposed model. Together with the theoretical ideas, the description and correlations of each variable are displayed in Fig. 1 , Table 1 and Table 2 . Table 1 below provides definition of the theoretical variables used in the Information Success (IS) model adapted from DeLone and McLean (2016) and TAM (Davis, 1989). Variable Role in Framework Possible Definition Opportunities Independent or Moderating Potential benefits such as improved patient care, efficiency, cost savings Challenges Variables Independent or Moderating The explanation was about the resistance to change by professionals, privacy of data, inadequacy of training. Facilitating Conditions Independent or Moderating Supportive infrastructure, policies, training programs Perceived Usefulness, Ease of Use Variables of Mediating from (TAM). It explains how the acceptance and use of digital tools can bring about solutions. Intention of behavior Variable of Dependent The reluctance of health workers System Use, User Satisfaction, Net Benefits Dependent Variables or Outcomes (from D&M) Reflect the success and outcome of digital health initiatives Table 2 The Technology Acceptance Model (TAM) and the DeLone and McLean Information Success Models are align the updated conceptual framework definition of each variable. Variables Definitions of this study Opportunities This study defines several technologies and digital tools that have been implemented in the healthcare system, including Open Medical Record System (Bahmni software), Laboratory Information Systems (LIS), Picture Archiving Communication System (PACS), Dagu, and digital health infrastructure. Challenges There are barriers that hamper the implementable of digital solutions in study settings up, including financial constraints, infrastructure limitations (internet not available, digital infrastructure and, electricity or generator), lack of trained staff, and technological issues. Policy, Training, Healthcare Insurance were facilitating conditions Policy frameworks at both national and regional levels play a crucial role in either supporting or hindering digitalization initiatives. Another key factor is the degree of of training that healthcare workers receive in utilizing digital tools. Additionally, comprehensive healthcare insurance coverage should be accessible to all citizens from every corner of the country, facilitating treatments through digital payment methods. Perceived Usefulness This variable predicts intentions and reflects net benefits, and its usefulness is accepted by users. Perceived Ease of Use The variables derive the usefulness and intention, which are influenced by the quality of digitalization system. Behavioral Intention This variable predicts the future use of a digitalization system based on perceived usefulness and perceived ease of use. System Use This variable determined whether they were actually engaged with the digitalization systems. User Satisfaction This variable uses both models to determine whether the quality of the system and its use result in net benefits. The Outcomes or net benefits of Healthcare System digitalization Better service delivery, improved patient care, increased access to healthcare, and enhanced healthcare equity are all expected results of digitalization. Theme 1: Opportunities Expanding their network and ensuring that there was enough electricity, including generators, helped both study sites’ efforts to digitalize the healthcare system. Additionally, the Open Medical Record System of Bahmni (OpenMRS) was deployed as a platform for the healthcare digitalization process, along with Laboratory Information Systems (LIS), Picture archiving communication system (PACS) for Radiology Imaging, Dagu for Pharmaceutical transactions in the pharmacy, and Odoo for financial transactions to facilitate digital methods. However, Ambo University Referral Hospital(AURH), has not yet started Dagu, Imaging, digital payments, and the logistic system has not been fully integrated with bidding, billing, and stock management, which poses challenges because its system has been partially digitalized. This was supported by the viewpoints of respondents. Given our current setup, several opportunities have arisen that encourage us to digitize our healthcare system. Some of the opportunities include improved access to healthcare services, better data management, and enhanced decision-making. These are expected outcomes from the digitalization efforts in this digital age and industry 4.0, to fully benefit the tertiary healthcare services. According to participant 3 of AHMC and AURH, these opportunities were made possible by: “It plays an important role in saving employee from the burden of carrying paper in many places” (participant 3 of AHMC). Additionally, noted by participant 6 of AURH as “it eliminates patient visits to laboratory and X-Ray results as it send online rather than manual, saving time for both patients and health professionals, and modernizing workflow” (Participant 6, AURH). Theme 2: Facilitating Conditions Sub-Theme 2.1 Strategies, Policy and planning At global, continental, and national levels, there have been strategies and plans have been put in place to facilitate the digitalization of healthcare. These include “the global digital strategy of the World Health Organization (WHO) from 2021–2025, the eService planning of African Union (AU) from 2021–2030, and “Digital Ethiopia: Inclusive Prosperity in 2025” of Ethiopian. Some low-resource countries are also working towards aligning with these strategies, policies, and plans in order to achieve the digitally inclusive prosperity outlined by Ethiopian to be competitive on a global scale. This sentiment was supported by the viewpoints of respondents: Sub-Theme 2.2 Healthcare Insurance Many Patients may not have their insurance book with them, or they may have expired without their knowledge, even though healthcare insurance has been adopted nationally. In some cases, insurance information is not visible at the health facility even if they have paid for it. This lack of documentation hinders the quality of treatments and leads to long wait times for services at health facilities. The introduction of digital payment methods for healthcare insurance has greatly facilitated the treatment process, reducing long wait times in queues. The perspective of AHMC respondent 4 has also been beneficial in this regard. “To obtain the card, individuals seeking health financing must visit the insurance department. The process of obtaining these can be lengthy, as they have to go to many places. Once they have the card, then they can come to us” (Participant 4, from AHMC, 2023). Sub-Theme 2.3 Training Support In this study, the theme of inadequate training is identified as a barrier to the implementation of digital healthcare in selected health facilities.This hindrance hampers the overall development and expansion of digitalization efforts in healthcare, preventing its sustained deployment in other health sectors. In 2023, AHMC participant 1 stated that There has been a lack of sufficient and consistent training, and computer supplies are not reaching every department. Additionally, participant 3 from the same health facility stated: “There is a significant problem with this situation. When we were assigned to this place; we didnot receive any training. We were simply told to go to the triage, and we went there without any awareness or training on EMR, exacerbating the issue. The process of health digitalization requires extensive training. According to participant 3 from the AHMC, Training is essential to familiarize oneself with the work environment. Another participant from AURH also highlighted the lack of training, stating: Owing to insufficient training, some medical personnel are hesitant to use the system, leading to errors. Additionally, he added that “Leaders lack proper training and do not share their experiences” (AURH8). In conclusion, the training was not adequate, which led to an inability to quickly write down patient complaints while they were being recorded them in the system. This, in turn, caused some healthcare professionals to be reluctant, raising questions. Theme 3: Challenges Theme 3.1: Infrastructure limitations In this study, the challenges that hinder effective use of digital healthcare were elaborated upon by participants from those sites: These challenges, as explained by participants in their health facilities, include the following: “Lack of a data center, absence of a backup server, insufficient availability of computers, difficulty scanning previous patient history, lack of connectivity between different machines and systems (e.g. X-Ray), certain healthcare workers’ unwillingness to use the system, insufficient training which resulting in mistakes, and leaders who are not properly trained and did not share their expertise were all mentioned by” (Participant 8, AURH). Long patient wait times, delayed generator response during power outages, a shortage of IT specialists in hospitals (we had to call them from the main campus), internet connection problems were also mentioned by participant 6 from the same facility ” (participant 6, AURH). Health facility face challenges due to a lack of resources, including the absence of a data center, pharmacy transactions (Dagu), inadequate training, and a shortage of ICT personnel at AURH to transition to paperless systems. Additionally, the participants from the radiology department of Adama Hospital Medical College who were involved in the project expressedtheir opinions as follows: “Expressed concerns about the system lack of maturity and the fact that digitalization efforts were not as active as expected” The image reading area was also overwhelmed by patients, making it difficult to focus on reading and defining images, leading to a lack of concentration. He added that issues with remote access for examining and altering image readings have also arisen, making it challenging to capture images of patients. The system lacked coherence, with inconsistent use forcing us to use Google Sheets to define images and minimize patient wait times in the department. However, maintaining performance and quality in accordance with the care provided at a medical facility would be advantageous for the systems. In conclusion, the system made the department dependent on ICT personnel to address and maintain activities” (Participant 30, AHMC). However, by consolidating multiple departments into a single central server of data center that uses separate servers for various functions, AHMC was leading of AURH in digitalization of the healthcare system. Additionally, challenges with radiology reading and defining patient data, as well as incomplete retention of paper work that researchers had intended to study in-depth during interviews and observations of the physical setups, were noted. In addition, other respondents from AURH expressed his opinion that he was encountering the system at AURH : “Lack of a data center, lack of backup server, insufficient availability of computers, difficulty in scanning previous patient history, lack of connectivity between various machines and systems “are further difficulties that participant 8 from AURH expressed” ( Participant 8, AURH). Moreover, Participant 4 from AHMC also expressed his thoughts: "The other issue is that, especially with the system operating 24 hours a day while people work only 8-hour shifts, there are problems with lighting, the system, the Network, and maintenance. To overcome this issue, IT staff must work around the clock”(Participant 14, AHMC). In addition, “Network and internet interruption sometimes occur due to loss of electric power. The generator starts quickly, and the system does not restart quickly even if the light returns to the middle, all the existing parts do not work ” (Participant 1, AHMC). Additionally, participant 7 from AURH highlighted three main challenges: “A lack of connectivity within the zonal health facilities, the inability to work offline like DHIS2, and the difficulty of customizing the local area network (LAN)” (Participant 7, AURH). Theme 3.2: Financial constraints In this study, several constraints also the results from the lack of a budgetary system by the government, as the project is run by nongovernmental organizations. The sustainability of the systems was never concerned. They focused only on until the project stockpile or expired. This will never fix the problems unless the government takes control of the system and manages it according to local circumstances. This supported by the following viewpoints: “ Among the various obstacles we have been facing thus far is the lack of ICT Professionals, only a few people receiving training, owing financial constraints”(Participant 16, from AHMC, 2023). Theme 4: Perceived Usefulness (PU) When opportunities are provided with all necessary resources, supported by facilitating conditions, and difficulties are minimized through national strategy, policy, and implementation issues, the perceived usefulness (PU) and perceived ease of use also affects the behavior of medical personnel and others system participants. This is further supported by the participants’ response who said: “I have no experience with it, but I am aware that this EMR system is helpful and will assist in further digitalization of the system,” She also added the usefulness of it. Another Participant added the usefulness of Digitalization of healthcare through the system as follows: “It was simplified the time for the patient to search their records, and has improved the treatment time for the physicians “(Participant 2, AHMC, 2023 ). Theme 5: Perceived Ease of Use (PEOU) Furthermore, Participant 3 from AHMC stated the PEOU of this system as follows: The digitalization of healthcare through EMR can easily enhance patients’ investigations in minutes as the laboratory technician, and imaging team defined their results as soon as they finished and saved. (Participant 3, AHMC, 2023). He also added other feedback: “Pointed out that the paper issue was completely overlooked, and as a result, this work was expanded to the remaining departments and facilities expressed by” (Participant 3, AHMC). In contrast, Participant 6 of AHMC stated its ease of use: “He stated that trained personnel rotate weekly between departments as part of a professional rotation; this system makes it unsuitable for ease of use in this manner”(Participant 6, AHMC). Theme 6: Behavioral intention The PU and PEOU significantly influence the changes in attitudes of all participants toward this digitalization initiative. Owing to their familiarity with the system, they have been using it more frequently in their daily tasks. This is because the top administration empowered them and made training and infrastructure readily, even if they were initially reluctant to use it. This is supported by participant feedback. “This were the right one that keeps digitalization from being implemented were the resistance of our professionals in using computer rather than manual due to insufficient training” (Participant 6, AHMC). Theme 7: System Use Instead of relying on manual methods, this article focuses on how professionals’ conduct has evolved even after they have received training and are legally obligated to apply it efficiently. The challenges of power outages, issue with internet access, and the equitable allocation of resources among all necessary departments are also addressed. This shift has made all healthcare professionals responsible and accountable for their daily activities in using the systems. Nonetheless, participants’ 30 from AHMC provided the following feedback: “If all our work as a hospital were done entirely to this EMR, it would save paper costs in the public office (reduce costs), do more work with less manpower (reduce transistors), and save time for the specialist “(Participant 3, AHMC). In contrast, participant 30 of the AHMC replied as followed: “The system is not active as we expected from the digitalization efforts, it is not well mature, the image reading area is also overwhelmed by patients while we are reading and defining image. Furthermore, instead of taking two separate patient images, I am accessing one to examine and make modify the picture if there is an issue with it. In addition, it lacks coherence, and the use of systems made us boring. We were forced to use “Google sheet” for defined images to minimize patient waiting from our department. To sum up, the system has made us reliant on IT staff to address urgent issues, allowing us to fully focus on our operations” (Participant 30, AHMC). This participant provided us with information about the current state of healthcare digitalization efforts in their department and suggested future steps that administrators should take to enhance it. It assisted by participant viewpoints: “For treatment in a study setting, it is better when the system improves our performance and quality at the same pace.” (Participant 30, AHMC). Another participant provided feedback on the system and explained it as follows: “The system needs improvement owing to inability work offline like District Health information software two (DHIS2),” (AURH7, 6). Theme 8: User Satisfaction The effectiveness of this theme depends on whether the professional used the system properly when in serving their customers, as opposed to serving them manually. “I am satisfied with the EMR developers, they were with us and they could easily fix it for us when the EMR system is interrupted” (Participant 3, AHMC). Theme 9: Net benefits of digitalized healthcare In this study, the digital healthcare outcome were enhanced by the proper use of digital tools and user satisfaction of EMR, LIS, Dagu, Imaging as the system not run independently. Digital healthcare insurance payment systems play a significant role in making this possible. The success of digitalization efforts relies heavily on healthcare providers who were proficient in use of these digital tools. This in turn, brought about enhanced care delivery, improved care quality, increase customer satisfactions, and brought tangible or effective and efficient usage of the system to be sustainable and the system should be extended to the remaining healthcare sectors by efficiently allocating resources. The respondents’ opinions supported this idea in the following ways: “This is good as we do paperless in “Central Triage”, and it would be nice if other departments like pharmacy, laboratory, and all departments or majors did it, especially if this work was expanded and the paper issue was left out completely” (Participant 3 from AHMC in 2023). When all of us work toward this system, it would save paper costs in the public office (reduce costs), do more work with less manpower (reduce transistors), and save time for the specialist” (Participant 3, from AHMC, 2023). Discussion This study focuses on nine thematic areas to fully understand the entire picture of healthcare digitalization opportunities, facilitating conditions, and challenges to arrive at its net benefits. Among these opportunities are included the Open Medical Record System (OpenMRS), LIS, PACS, and Dagu. In both research locations, these prospects were still in their infancy, as observed in a study by (31) conducted in Northwest Ethiopia in the Amhara Regional State, in which picture archiving and communication systems (PACS) usage was low in low- resourced countries. In relation to PACS, Open MRS was utilized in AHMC replacing paper work; however, paper usage was not fully abandoned throughout the facility. AURH uses both paper work and the system side-by-side in implemented units, as they cannot abandon paper work since it is not deployed in all units or departments. This finding also indicated that OpenMRS was not mature enough to be used universally. This finding is consistent with a previous finding that approximately 51.8% of respondents reported challenges accessing resources due to their young age groups of under 35 years (12,32). Furthermore, digital health presents promising opportunities in Oromia despite infrastructure constraints. Participants highlighted improved communication between providers, better tracking of patient information, enhancing decision-making capabilities, and referral systems as major gains. These findings align with studies in other Low and middle-income countries (LMICs), where digitalization has enabled more efficient data sharing, quicker clinical decision, faster diagnosis and enhanced continuity of care (9,33,34). Additionally, the presence of motivated health workers and an increasing interest in technology among younger professionals was seen as a positive sign or as a foundation for digital heath adoption for future digital uptake. In addition, other moderating variables or independent variables were facilitators included nongovernmental organization support, occasional government-led initiatives, and pilot programs introducing open medical record tools. The participants emphasized the importance of consistent technical assistance, reliable training, and organizational support. This aligns with the Unified Theory of Acceptance and Use of Technology, where facilitating conditions are crucial for adoption (35,36). Despite these favorable circumstances, numerous issues were noted, including erratic internet access, frequent power outages, a lack of digital infrastructure, poor training, a lack of technological know-how, and user resistance to change. Similar to previous studies conducted in Sub-Saharan Africa, these obstacles suggest systemic flaws that hinder the transformation of digital health World Health Organization (WHO), (37,38). Concerns about data privacy and unclear policy frameworks were also raised by participants. Additionally, the digitalization of e-learning platforms and decision- support technologies has helped alleviate the shortage of qualified healthcare workers in areas with insufficient resources (39). This enabled by virtual sessions organized through e-learning to offer various courses to enhance their abilities and expertise of various healthcare professionals (40). Similarly, the inadequacy of trained healthcare workers in treatment and diagnosis can be supported by an accurate Artificial Intelligence-based(AI-based) tool available to offer prompt decisions through decision support tools (41–44). By gathering real-time data digitally, digitalization can monitor and control public health in dealing with communicable diseases and health catastrophes without endangering the public (45).Effective management of scarce medical supplies and equipment is essential in low-resource nations (46–48)).However, digitalization can play a significant role in managing their supply chain through inventory management systems and remote health center support via Telehealth(49). Furthermore, a digital system allows for real-time tracking of medical equipment and supplies, ensuring their availability in stock, minimizing waste and monitoring drug expiration dates. It also help in identifying shortages early, thereby ensuring the timely delivery of important supplies (50–52). Additionally, by utilizing digital tools, telehealth significantly reduces certain shortages (53). It offers the ability to request supplies, consult with experts online, and ensure important resources for delivering care are available. In adapting to these challenges, some participants with experience in digital systems found them useful, especially for reducing administrative burdens, improving patient tracking, and accelerating service delivery. These perceptions align with the Technology Acceptance Model (TAM), which emphasizes perceived usefulness as a key predictor of technology adoption (26,54).Some respondents who were not familiar with digital tools, however, were nonetheless skeptical of their usefulness. User-friendliness was a major consideration, especially for both older and technologically adept personnel. System deemed intuitive for digital health products featuring local language assistance have increased their engagement. On the other hand, the lack of a user-centered design was frequently mentioned as a barrier, which shown by previous research (55). This emphasizes the importance of digital health solutions aligning with users’ cognitive and environmental realities. While several participants expressed a willingness to adopt digital tools, their actual intention depended on their prior experience, availability of support, and perceived relevance to those who believed the tools would directly improve their workflow. Behavioral intention was greater among those who believed that digital tools would ease their workload. Behavioral intention is shaped by both perceived usefulness and ease of use, according to the UTAUT and TAM frameworks (26,36,56). Moreover, the actual system use was sporadic and often limited to pilot phases. Equipment failure, worker turnover, and lack of continuous training all hindered its sustainability. This emphasizes the gap between pilot performance and long-term adoption, as observed in the literature on global digital health by (27,57). The satisfactions of users are directly related to the availability of systems performance and support. When training was adequate and systems operated smoothly, participants expressed satisfaction. Dissatisfaction arose when tools were unreliable or when users felt unprepared to operate them. These findings reveal that satisfaction depends on both system reliability and user confidence (27,58,59). Those who had proper training and had operational mechanisms in place reported positive experiences. Others, especially those in remote areas with frequent system crashes, reported frustration. Reliability, assistance, and perceived personal benefits were strongly correlated with satisfaction. However, these benefits were unevenly distributed and undermined by contextual barriers. Prior studies confirmed that digital health benefits are contingent on contextual fit and support infrastructure (60,61). It was context-dependent and aligns with the improved readiness and acceptance found in the study. Approximately 60% of health professionals show readiness in adopting EMRs if they are younger, skilled in using computers, digitally literate, and own their personal computer (62). These factors serve as predictors for EMR adoption. Furthermore, it enhances health data quality, retrievability, and traceability even through smartphones, enabling real-time documentation (13,63). This assists healthcare workers modernizing their efficiency of health management and making accountability stronger than traditional treatment. This also leads health executives and physicians to perceive digital systems as effective methods in reducing their workload and improving health service quality with the sufficient availability of devices and internet access being acknowledged (64).Chereka et al and Kasaye et al,, explained the net benefits that were aligned with participants thought in empowering digitalization through training and digital literacy. This boosted digital health literacy among professions, developed positive attitudes, perceived usefulness, and initiated training significantly (65,66). These factors motivated readiness and laid the groundwork for broad adoption throughout the region. The study highlights the benefits of digital systems in healthcare, including time savings, better coordination, and improved patient tracking. The study faces limitations including resource shortages, delayed data collection, oversampling of male healthcare professionals, and the use of qualitative methods, with only two hospitals selected from 114. Conclusions This study emphasizes the need for a multi- stakeholder approach, including infrastructure investment, capacity building, user-centered design, and sustained policy commitment, to fully realize the potential of digital health in low-resource settings. Recommendation The author recommends further research on electronic health records, investigating data privacy concerns, and conducting a survey to alleviate patient reluctance about the digitalization of healthcare. Abbreviations AHMC Adama Hospital Medical College AI Artificial Intelligence AURH Ambo University Referral Hospital DM ISM DeLone and McLean Information Success Model LIS Laboratory Information System LMICs Low-and middle-income countries OpenMRS Open Medical Record System PACS Picture Archiving Communication Software TAM Technology Acceptance Model UTAUT Unified Technology Acceptance W.H.O World Health Organization Declarations Ethics approval and consent to participate: This study was conducted in accordance with the ethical principles outlined in the declaration of Helsinki (https://www.wma.net/policies-post/wma-declaration-of-helsinki/). The ethical approval was obtained from Jimma University, Institute of Technology under reference number (Ref. No: Comp/JiT/019/2015 E.C). Informed consent was obtained from all individual participants included in the study. Consent for publication In this study, consent for publication was not mandatory, as the study did not involve humans but rather focused on systems and how they operate when compared to manual methods. Availability of data and materials The data supporting the finding of this study are available from the corresponding author upon reasonable request. Competing interests All authors have no conflicts of interest on this manuscript. Funding Jimma University, Institute of Technology, AHMC, and Dar al Fiker Foundation were funded solely for the purpose of data collection. Authors' contributions The principal investigator designs, collects, analyzes, and writes up the manuscript. Authors Three and four also contribute to shaping the design strategies to best fit, constructing the analysis of the principal investigator’s ideas by adding their input, including comments or feedback. 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1","display":"","copyAsset":false,"role":"figure","size":61901,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eShows the Conceptual Framework for Healthcare Digitalization, adapted from DeLone and McLean IS Success Model (DeLone\u0026amp; McLean, 2016) and the Technology Acceptance Model (Davis, 1989).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7528690/v1/4cb238a11f46e0d6a445d433.png"},{"id":91968519,"identity":"7def61f8-c3d4-4e9d-acad-527c6c56fcff","added_by":"auto","created_at":"2025-09-23 08:44:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1062654,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7528690/v1/14845918-d633-42d8-aa07-33c33fbd73b5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Digitalization of healthcare in low-resourced settings: Opportunities and challenges, Qualitative study in Oromia, Ethiopia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDigitalization has played a significant role in the widespread transformation of healthcare systems worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Many healthcare facilities in low-resource countries, whether rural or urban, were operated manually, making them difficult to access due to the immaturity of their implementation or deployment (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This full adoption of digitalization has addressed the issue of restricted access by allowing remote patient-physician communication through telemedicine or mobile health (mHealth). With the advent of digitalization, patients were consulting their physicians remotely through telephone or video calls (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). This has helped reduce transportation costs and eliminate long wait times associated with in-person appointments, which can sometimes last for two or more days. This not saves money but also saves time for both doctors and patients. Furthermore, the integration of digital technologies has enhanced healthcare delivery in low-resource countries by decreasing the need for human labor and physical resources (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This advancement was further realized through the adoption of Electronic Medical Records (EMRs), which enabled healthcare providers to maintain comprehensive digital documentation of patient information, including medical histories, treatment plans, and diagnostic results. Furthermore, the utilization of digital technologies in low-resource countries has allowed public health initiatives to create opportunities for raising awareness through educational campaigns even in settings with limited resources (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). To disseminate knowledge on maternal health, immunization, sanitation, and appointment scheduling, digital tools such as mobile applications, SMS, and short films are utilized (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). These tools facilitate the delivery of instructional materials directly to people\u0026rsquo;s home, even for those residing in areas with limited internet access (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Additionally, digital platforms can facilitated the creation of virtual health communities, which allowed individuals to easily share experiences, receive peer support, and ask questions related to management of mental health issues and specific chronic illnesses (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In the same vein, digitalization has brought significant opportunities for improving healthcare delivery (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This is achieved by reducing overall costs through the elimination of manual administrative tasks, decreasing reliance on physical infrastructure, and minimizing the use of paper records in resource-constrained countries including the study health facilities. However, several factors have significantly hindered the progress of healthcare digitalization. First, infrastructural deficit such as a limited number of computers, the unequal distribution of smartphones, unreliable electricity, and insufficient internet connectivity that substantially impede the effective deployment and use of digital health systems effectively in low-and middle-income countries (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Secondly, insufficient financial investment in training and incentives for both healthcare and non-healthcare personnel exacerbates implementation challenges; several eHealth system fail because of low workforce, low digital literacy, limited opportunities for professional development and a lack of adequate technical support, further hindering the ability of individuals to build competency (13). Third, the absence of formalized incentives and compensation plans for community health workers and other lay health workers contributes to lower motivation, job satisfaction, and engagement levels, and heightens attrition, which often occurs because of delayed or missing payment, undermining digital health activities (14). Finally, a persistent imbalance in the healthcare worker-to-patient ratio in resource-poor settings further constrains the scalability and sustainability of digital health programs (15\u0026ndash;17). Additionally, the digitalization of healthcare has been implemented only in specific healthcare facilities that have access to electricity or generators, and internet, which are not always reliable(18). This led to the loss of important data feeds, and very low level of digital literacy among healthcare providers. These included insufficient training and a lack of awareness among the general population. There are significant yet undetectable challenges related to security and privacy concerns in many low-resourced countries. To address these issues (security and privacy), the relevant authorities must enforce the laws that everyone must adhere to (19).Punishments should be imposed on those who engage in cybercrimes, whether they do so anonymously or not. This is crucial for safeguarding patient data from unauthorized monitoring in low-resourced countries due to underdeveloped cyber-security infrastructure and a lack of trained personnel in this area. Another issue in our nation was the immaturity of healthcare financing. This is because not all districts and regions are included in the system and did not have agreements with healthcare institutions or hospital (20). In contrast, digital technology has the potential to help overcome these obstacles and determinants to improve healthcare outcomes in settings with limited resources (21). Despite this attempt, the selected health facilities initiated the implementation of digitalization to overcome the paper-laden and loss of patient information, which resulted in long wait times that have not yet been resolved. The researcher used in-depth interviews and site observations to collect data from participants, with the goal of qualitatively addressing this issue and uncovering hidden insights that hinder full-scale digitalization in various areas. What are the opportunities and challenges associated with the digitalization of healthcare in low-resourced settings, specifically in Oromia, Ethiopia? This study aims to identified the potential opportunities and barriers of digitalization in Oromia, Ethiopia\u0026rsquo;s healthcare system, focusing on healthcare professionals\u0026rsquo; access and perception of digital tools\u0026rsquo; in healthcare delivery\u003c/p\u003e"},{"header":"Methods and Materials","content":"\u003cp\u003eThe qualitative research design with case study for in-depth analysis of the digitalization efforts is used (22). Therefore, a case study research design was employed to examine the effective utilization of digitalization efforts that improve healthcare information systems.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSettings and gaining access to a community\u003c/h2\u003e\u003cp\u003e The Eastern and Western Oromia Regional States of Ethiopia are home to two tertiary healthcare facilities: Adama Specialized Hospital and Medical college (AHMC) located in Adama, and Ambo University Referral Hospital (AURH) in Ambo. Jimma University\u0026rsquo;s Institute of Technology granted the lead investigator ethical clearance and a letter of approval for data collection. He then forwarded these documents to the appropriate authorities to obtain access. Several medical professionals were scheduled for in-depth interviews to gather information on healthcare digitalization initiatives. Through this process, the researcher selected key informants from the healthcare industry who have expertise in digital health activities, including the challenges and opportunities associated with enhancing digital health practices at specific healthcare institutions in low-resource countries.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eQualitative Case study Method\u003c/h3\u003e\n\u003cp\u003eTwo healthcare facilities were selected from a total of 114 health facilities and four tertiary specialized hospitals in the region. These two facilities were chosen purposefully because they had already started the process of digitalization, unlike the other healthcare facilities in the region.\u003c/p\u003e\n\u003ch3\u003eData collection methods\u003c/h3\u003e\n\u003cp\u003eBased on their continuous involvement in digitalization initiatives, the primary investigator selected thirty healthcare workers from both facilities. Data collectors were hired to conduct in-depth interviews using reference number (Comp/JiT/019/2015 E.C) from Jimma University, Institute of Technology. The principal investigator developed the interview tools based on our main dissertation, which is uploaded as a supplementary file in this study. However, the authors (Tiya et al., 2025) used the respondents in the forthcoming article by Sage, in addition to one respondent for this study (23). Each respondent was asked to volunteer to participate in the study. Using predetermined time limits, the authors and data collectors aimed to conduct interviews that did not exceed one hour, with in-depth interviews lasting a minimum of half an hour. To reduce researcher bias and allow respondents to express their opinions openly, impartial observers were hired to serve as interviewers during the qualitative data collection process. A total of 1740 minutes were needed to collect the data. Data gathering for Ambo University Referral Hospital (AURH) took place over one month (from November 21-December 20) in 2024, as the system did not launch until that year. In contrast, data collection for AHMC occurred over three consecutive months, like June 1-August 30, 2023. The time was adjusted to the appropriate time and date of the respondents' consent. To preserve authenticity and guarantee the anonymity of respondents\u0026rsquo; opinions in our research data, in-depth interviews were conducted by collectors alongside the researcher\u0026rsquo;s physical observations. Lastly, the data are ready for transcription, ensuring dependability, conformability, trustworthiness and credibility, as described in the next section of this manuscript.\u003c/p\u003e\n\u003ch3\u003eData Quality Control Methods\u003c/h3\u003e\n\u003cp\u003e To ensure the quality of the qualitative methods, the authors followed the steps outlined by (24,25). The recorded audio of respondents was listened to several times, with authors rehearsing their thoughts to transcribe them accurately without missing any details. These textual data were then reviewed by linguists, who compared them to the recorded audio to ensure trustworthiness and accuracy. Afterward, the linguists identified themes related to opportunities, challenges, and strategies to overcome them, highlighting these with appropriate codes. In this study, in-depth interviews were conducted to maintain authenticity, including all the units of data that the system could process to uncover new or hidden insights from the interviewees for further analysis aligned to the models.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe Integration of the DeLone and McLean Information System Success Model (DMISSM) and Technology Acceptance Model (TAM) in the theoretical framework.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTechnology Acceptance Model: It is a paradigm for understanding user adoption of new technology created by Fred Davis (26). It suggests that perceived usefulness (PU) and perceived ease of use (PEOU) are key factors influencing a user's choice to use a new system. Healthcare workers' perceptions of the system's ease of use and its effectiveness in improving their daily tasks are crucial factors in determining adoption. Qualitative interviews with healthcare professionals can help investigate these perceptions and their intentions towards using the system. In inquiring about how they feel the technology helps or hinders their daily tasks and how challenging it is to use.\u003c/p\u003e\u003cp\u003eDeLone and McLean Information Systems (IS) Success Model: It is a broader framework that evaluates the success of an information system. Unlike TAM, which focuses on individual user acceptance, this model looks at success from a multi-dimensional perspective (27\u0026ndash;29). It proposes that the success of an Information Systems is dependent on six interconnected dimensions: The DeLone and McLean IS Success Model is a multi-dimensional framework that evaluates the success of healthcare digitalization in information system lenses. It focuses on six interconnected dimensions: System Quality, Information Quality, Service Quality, Use, User Satisfaction, and Net Benefits. System Quality refers to the technical quality of the system, including reliability, ease of use, and security. Information Quality deals with the quality of the information produced by the system, such as accuracy, timeliness, and completeness. Service Quality focuses on the quality of support provided by the Information System department or vendors. The ultimate measure of success is Net Benefits, which refers to the system's impact on individuals, organizations, and society. A qualitative study would use this model to structure interview questions and observations to understand the opportunities and challenges from each of these perspectives.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eThe authors repeatedly reviewed the text data to align the themes with their corresponding codes for the analysis of observational data and in-depth interviews until they identified the intended themes. The data were subsequently imported into qualitative data analysis software, specifically MAXQDA (30). Furthermore, a pattern of developmental themes was developed via both deductive and inductive approaches. In this process, the Technology Acceptance Model (TAM) and the DeLone and McLean Information Success Model (DMISM) served as templates for deductive analysis. Finally, the researchers carefully reviewed the coded interview text to determine appropriate patterns that align or are linked to the models for the successful implementation of digitalization efforts in healthcare systems. Further details will be provided in the subsequent section of the results.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study revealed that inductive analysis was conducted through data-driven analysis, and focused on the acceptance of technology and the information success model of DeLone and McLean deductively. In addition to the two established models, this analysis also explored other aspects such as infrastructure, training, and policy, as moderating variables. The newly proposed theoretical model reflects the deep-rooted factors necessary in determining the acceptance and success of healthcare digitalization efforts in tertiary health facilities, facilitating them in a selected healthcare context. These factors include infrastructure issues, policies, training support, healthcare insurance status, and healthcare system outcomes or net benefits expected from holistic improvements in healthcare services. These factors were used as a guide for the newly proposed model. Together with the theoretical ideas, the description and correlations of each variable are displayed in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ebelow provides definition of the theoretical variables used in the Information Success (IS) model adapted from DeLone and McLean (2016) and TAM (Davis, 1989).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRole in Framework\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePossible Definition\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOpportunities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndependent or Moderating\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePotential benefits such as improved patient care, efficiency, cost savings\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChallenges\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVariables Independent or Moderating\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThe explanation was about the resistance to change by professionals, privacy of data, inadequacy of training.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFacilitating Conditions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndependent or Moderating\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSupportive infrastructure, policies, training programs\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived Usefulness, Ease of Use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVariables of Mediating from (TAM).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIt explains how the acceptance and use of digital tools can bring about solutions.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntention of behavior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVariable of Dependent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThe reluctance of health workers\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSystem Use, User Satisfaction, Net Benefits\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDependent Variables or Outcomes (from D\u0026amp;M)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReflect the success and outcome of digital health initiatives\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe Technology Acceptance Model (TAM) and the DeLone and McLean Information Success Models are align the updated conceptual framework definition of each variable.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDefinitions of this study\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eOpportunities\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eThis study defines several technologies and digital tools that have been implemented in the healthcare system, including Open Medical Record System (Bahmni software), Laboratory Information Systems (LIS), Picture Archiving Communication System (PACS), Dagu, and digital health infrastructure.\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eChallenges\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eThere are barriers that hamper the implementable of digital solutions in study settings up, including financial constraints, infrastructure limitations (internet not available, digital infrastructure and, electricity or generator), lack of trained staff, and technological issues.\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePolicy, Training, Healthcare Insurance were facilitating conditions\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003ePolicy frameworks at both national and regional levels play a crucial role in either supporting or hindering digitalization initiatives. Another key factor is the degree of of training that healthcare workers receive in utilizing digital tools. Additionally, comprehensive healthcare insurance coverage should be accessible to all citizens from every corner of the country, facilitating treatments through digital payment methods.\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePerceived Usefulness\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eThis variable predicts intentions and reflects net benefits, and its usefulness is accepted by users.\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePerceived Ease of Use\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eThe variables derive the usefulness and intention, which are influenced by the quality of digitalization system.\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eBehavioral Intention\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eThis variable predicts the future use of a digitalization system based on perceived usefulness and perceived ease of use.\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eSystem Use\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eThis variable determined whether they were actually engaged with the digitalization systems.\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eUser Satisfaction\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eThis variable uses both models to determine whether the quality of the system and its use result in net benefits.\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eThe Outcomes or net benefits of Healthcare System digitalization\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eBetter service delivery, improved patient care, increased access to healthcare, and enhanced healthcare equity are all expected results of digitalization.\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eTheme 1: Opportunities\u003c/h3\u003e\n\u003cp\u003eExpanding their network and ensuring that there was enough electricity, including generators, helped both study sites\u0026rsquo; efforts to digitalize the healthcare system. Additionally, the Open Medical Record System of Bahmni (OpenMRS) was deployed as a platform for the healthcare digitalization process, along with Laboratory Information Systems (LIS), Picture archiving communication system (PACS) for Radiology Imaging, Dagu for Pharmaceutical transactions in the pharmacy, and Odoo for financial transactions to facilitate digital methods. However, Ambo University Referral Hospital(AURH), has not yet started Dagu, Imaging, digital payments, and the logistic system has not been fully integrated with bidding, billing, and stock management, which poses challenges because its system has been partially digitalized. This was supported by the viewpoints of respondents. Given our current setup, several opportunities have arisen that encourage us to digitize our healthcare system. Some of the opportunities include improved access to healthcare services, better data management, and enhanced decision-making. These are expected outcomes from the digitalization efforts in this digital age and industry 4.0, to fully benefit the tertiary healthcare services.\u003c/p\u003e\u003cp\u003eAccording to participant 3 of AHMC and AURH, these opportunities were made possible by:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;It plays an important role in saving employee from the burden of carrying paper in many places\u0026rdquo; (participant 3 of AHMC). Additionally, noted by participant 6 of AURH as \u0026ldquo;it eliminates patient visits to laboratory and X-Ray results as it send online rather than manual, saving time for both patients and health professionals, and modernizing workflow\u0026rdquo; (Participant 6, AURH).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eTheme 2: Facilitating Conditions\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eSub-Theme 2.1 Strategies, Policy and planning\u003c/h2\u003e\u003cp\u003eAt global, continental, and national levels, there have been strategies and plans have been put in place to facilitate the digitalization of healthcare. These include \u0026ldquo;the global digital strategy of the World Health Organization (WHO) from 2021\u0026ndash;2025, the eService planning of African Union (AU) from 2021\u0026ndash;2030, and \u0026ldquo;Digital Ethiopia: Inclusive Prosperity in 2025\u0026rdquo; of Ethiopian. Some low-resource countries are also working towards aligning with these strategies, policies, and plans in order to achieve the digitally inclusive prosperity outlined by Ethiopian to be competitive on a global scale. This sentiment was supported by the viewpoints of respondents:\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eSub-Theme 2.2 Healthcare Insurance\u003c/h2\u003e\u003cp\u003eMany Patients may not have their insurance book with them, or they may have expired without their knowledge, even though healthcare insurance has been adopted nationally. In some cases, insurance information is not visible at the health facility even if they have paid for it. This lack of documentation hinders the quality of treatments and leads to long wait times for services at health facilities. The introduction of digital payment methods for healthcare insurance has greatly facilitated the treatment process, reducing long wait times in queues.\u003c/p\u003e\u003cp\u003eThe perspective of AHMC respondent 4 has also been beneficial in this regard.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;To obtain the card, individuals seeking health financing must visit the insurance department. The process of obtaining these can be lengthy, as they have to go to many places. Once they have the card, then they can come to us\u0026rdquo; (Participant 4, from AHMC, 2023).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eSub-Theme 2.3 Training Support\u003c/h2\u003e\u003cp\u003eIn this study, the theme of inadequate training is identified as a barrier to the implementation of digital healthcare in selected health facilities.This hindrance hampers the overall development and expansion of digitalization efforts in healthcare, preventing its sustained deployment in other health sectors.\u003c/p\u003e\u003cp\u003eIn 2023, AHMC participant 1 stated that\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThere has been a lack of sufficient and consistent training, and computer supplies are not reaching every department.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdditionally, participant 3 from the same health facility stated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;There is a significant problem with this situation. When we were assigned to this place; we didnot receive any training. We were simply told to go to the triage, and we went there without any awareness or training on EMR, exacerbating the issue. The process of health digitalization requires extensive training.\u003c/p\u003e\u003cp\u003eAccording to participant 3 from the AHMC,\u003c/p\u003e\u003cp\u003eTraining is essential to familiarize oneself with the work environment.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAnother participant from AURH also highlighted the lack of training, stating:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eOwing to insufficient training, some medical personnel are hesitant to use the system, leading to errors.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdditionally, he added that\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Leaders lack proper training and do not share their experiences\u0026rdquo; (AURH8).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn conclusion, the training was not adequate, which led to an inability to quickly write down patient complaints while they were being recorded them in the system. This, in turn, caused some healthcare professionals to be reluctant, raising questions.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eTheme 3: Challenges\u003c/h2\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003eTheme 3.1: Infrastructure limitations\u003c/h2\u003e\u003cp\u003eIn this study, the challenges that hinder effective use of digital healthcare were elaborated upon by participants from those sites: These challenges, as explained by participants in their health facilities, include the following:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Lack of a data center, absence of a backup server, insufficient availability of computers, difficulty scanning previous patient history, lack of connectivity between different machines and systems (e.g. X-Ray), certain healthcare workers\u0026rsquo; unwillingness to use the system, insufficient training which resulting in mistakes, and leaders who are not properly trained and did not share their expertise were all mentioned by\u0026rdquo; (Participant 8, AURH). Long patient wait times, delayed generator response during power outages, a shortage of IT specialists in hospitals (we had to call them from the main campus), internet connection problems were also mentioned by participant 6 from the same facility\u003cem\u003e\u0026rdquo; (participant 6, AURH).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eHealth facility face challenges due to a lack of resources, including the absence of a data center, pharmacy transactions (Dagu), inadequate training, and a shortage of ICT personnel at AURH to transition to paperless systems.\u003c/p\u003e\u003cp\u003eAdditionally, the participants from the radiology department of Adama Hospital Medical College who were involved in the project expressedtheir opinions as follows:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Expressed concerns about the system lack of maturity and the fact that digitalization efforts were not as active as expected\u0026rdquo; The image reading area was also overwhelmed by patients, making it difficult to focus on reading and defining images, leading to a lack of concentration. He added that issues with remote access for examining and altering image readings have also arisen, making it challenging to capture images of patients. The system lacked coherence, with inconsistent use forcing us to use Google Sheets to define images and minimize patient wait times in the department. However, maintaining performance and quality in accordance with the care provided at a medical facility would be advantageous for the systems. In conclusion, the system made the department dependent on ICT personnel to address and maintain activities\u0026rdquo; (Participant 30, AHMC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eHowever, by consolidating multiple departments into a single central server of data center that uses separate servers for various functions, AHMC was leading of AURH in digitalization of the healthcare system. Additionally, challenges with radiology reading and defining patient data, as well as incomplete retention of paper work that researchers had intended to study in-depth during interviews and observations of the physical setups, were noted.\u003c/p\u003e\u003cp\u003e\u003cem\u003eIn addition, other respondents from AURH expressed his opinion that he was encountering the system at AURH\u003c/em\u003e:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Lack of a data center, lack of backup server, insufficient availability of computers, difficulty in scanning previous patient history, lack of connectivity between various machines and systems \u0026ldquo;are further difficulties that participant 8 from AURH expressed\u0026rdquo; ( Participant 8, AURH).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eMoreover, Participant 4 from AHMC also expressed his thoughts:\u003c/h2\u003e\u003cp\u003e\"The other issue is that, especially with the system operating 24 hours a day while people work only 8-hour shifts, there are problems with lighting, the system, the Network, and maintenance. To overcome this issue, IT staff must work around the clock\u0026rdquo;(Participant 14, AHMC).\u003c/p\u003e\u003cp\u003eIn addition,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Network and internet interruption sometimes occur due to loss of electric power. The generator starts quickly, and the system does not restart quickly even if the light returns to the middle, all the existing parts do not work \u0026rdquo; (Participant 1, AHMC).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdditionally, participant 7 from AURH highlighted three main challenges:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;A lack of connectivity within the zonal health facilities, the inability to work offline like DHIS2, and the difficulty of customizing the local area network (LAN)\u0026rdquo; (Participant 7, AURH).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eTheme 3.2: Financial constraints\u003c/h2\u003e\u003cp\u003eIn this study, several constraints also the results from the lack of a budgetary system by the government, as the project is run by nongovernmental organizations. The sustainability of the systems was never concerned. They focused only on until the project stockpile or expired. This will never fix the problems unless the government takes control of the system and manages it according to local circumstances. This supported by the following viewpoints:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo; Among the various obstacles we have been facing thus far is the lack of ICT Professionals, only a few people receiving training, owing financial constraints\u0026rdquo;(Participant 16, from AHMC, 2023).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eTheme 4: Perceived Usefulness (PU)\u003c/h2\u003e\u003cp\u003eWhen opportunities are provided with all necessary resources, supported by facilitating conditions, and difficulties are minimized through national strategy, policy, and implementation issues, the perceived usefulness (PU) and perceived ease of use also affects the behavior of medical personnel and others system participants.\u003c/p\u003e\u003cp\u003eThis is further supported by the participants\u0026rsquo; response who said: \u0026ldquo;I have no experience with it, but I am aware that this EMR system is helpful and will assist in further digitalization of the system,\u0026rdquo; She also added the usefulness of it.\u003c/p\u003e\u003cp\u003eAnother Participant added the usefulness of Digitalization of healthcare through the system as follows:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It was simplified the time for the patient to search their records, and has improved the treatment time for the physicians \u0026ldquo;(Participant 2, AHMC, 2023\u003c/em\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eTheme 5: Perceived Ease of Use (PEOU)\u003c/h2\u003e\u003cp\u003eFurthermore, Participant 3 from AHMC stated the PEOU of this system as follows:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe digitalization of healthcare through EMR can easily enhance patients\u0026rsquo; investigations in minutes as the laboratory technician, and imaging team defined their results as soon as they finished and saved. (Participant 3, AHMC, 2023).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eHe also added other feedback:\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e \u0026ldquo;Pointed out that the paper issue was completely overlooked, and as a result, this work was expanded to the remaining departments and facilities expressed by\u0026rdquo; (Participant 3, AHMC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eIn contrast, Participant 6 of AHMC stated its ease of use:\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;He stated that trained personnel rotate weekly between departments as part of a professional rotation; this system makes it unsuitable for ease of use in this manner\u0026rdquo;(Participant 6, AHMC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eTheme 6: Behavioral intention\u003c/h2\u003e\u003cp\u003eThe PU and PEOU significantly influence the changes in attitudes of all participants toward this digitalization initiative. Owing to their familiarity with the system, they have been using it more frequently in their daily tasks. This is because the top administration empowered them and made training and infrastructure readily, even if they were initially reluctant to use it.\u003c/p\u003e\u003cp\u003eThis is supported by participant feedback.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;This were the right one that keeps digitalization from being implemented were the resistance of our professionals in using computer rather than manual due to insufficient training\u0026rdquo; (Participant 6, AHMC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eTheme 7: System Use\u003c/h2\u003e\u003cp\u003eInstead of relying on manual methods, this article focuses on how professionals\u0026rsquo; conduct has evolved even after they have received training and are legally obligated to apply it efficiently. The challenges of power outages, issue with internet access, and the equitable allocation of resources among all necessary departments are also addressed.\u003c/p\u003e\u003cp\u003eThis shift has made all healthcare professionals responsible and accountable for their daily activities in using the systems.\u003c/p\u003e\u003cp\u003eNonetheless, participants\u0026rsquo; 30 from AHMC provided the following feedback:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If all our work as a hospital were done entirely to this EMR, it would save paper costs in the public office (reduce costs), do more work with less manpower (reduce transistors), and save time for the specialist \u0026ldquo;(Participant 3, AHMC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn contrast, participant 30 of the AHMC replied as followed:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The system is not active as we expected from the digitalization efforts, it is not well mature, the image reading area is also overwhelmed by patients while we are reading and defining image. Furthermore, instead of taking two separate patient images, I am accessing one to examine and make modify the picture if there is an issue with it.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eIn addition, it lacks coherence, and the use of systems made us boring. We were forced to use \u0026ldquo;Google sheet\u0026rdquo; for defined images to minimize patient waiting from our department.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eTo sum up, the system has made us reliant on IT staff to address urgent issues, allowing us to fully focus on our operations\u0026rdquo; (Participant 30, AHMC).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis participant provided us with information about the current state of healthcare digitalization efforts in their department and suggested future steps that administrators should take to enhance it.\u003c/p\u003e\u003cp\u003eIt assisted by participant viewpoints:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;For treatment in a study setting, it is better when the system improves our performance and quality at the same pace.\u0026rdquo; (Participant 30, AHMC).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAnother participant provided feedback on the system and explained it as follows:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The system needs improvement owing to inability work offline like District Health information software two (DHIS2),\u0026rdquo; (AURH7, 6).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eTheme 8: User Satisfaction\u003c/h2\u003e\u003cp\u003eThe effectiveness of this theme depends on whether the professional used the system properly when in serving their customers, as opposed to serving them manually.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e \u0026ldquo;I am satisfied with the EMR developers, they were with us and they could easily fix it for us when the EMR system is interrupted\u0026rdquo; (Participant 3, AHMC).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eTheme 9: Net benefits of digitalized healthcare\u003c/h2\u003e\u003cp\u003eIn this study, the digital healthcare outcome were enhanced by the proper use of digital tools and user satisfaction of EMR, LIS, Dagu, Imaging as the system not run independently. Digital healthcare insurance payment systems play a significant role in making this possible. The success of digitalization efforts relies heavily on healthcare providers who were proficient in use of these digital tools.\u003c/p\u003e\u003cp\u003eThis in turn, brought about enhanced care delivery, improved care quality, increase customer satisfactions, and brought tangible or effective and efficient usage of the system to be sustainable and the system should be extended to the remaining healthcare sectors by efficiently allocating resources. The respondents\u0026rsquo; opinions supported this idea in the following ways:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;This is good as we do paperless in \u0026ldquo;Central Triage\u0026rdquo;, and it would be nice if other departments like pharmacy, laboratory, and all departments or majors did it, especially if this work was expanded and the paper issue was left out completely\u0026rdquo; (Participant 3 from AHMC in 2023).\u003c/p\u003e\u003cp\u003eWhen all of us work toward this system, it would save paper costs in the public office (reduce costs), do more work with less manpower (reduce transistors), and save time for the specialist\u0026rdquo; (Participant 3, from AHMC, 2023).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study focuses on nine thematic areas to fully understand the entire picture of healthcare digitalization opportunities, facilitating conditions, and challenges to arrive at its net benefits. Among these opportunities are included the Open Medical Record System (OpenMRS), LIS, PACS, and Dagu. In both research locations, these prospects were still in their infancy, as observed in a study by (31) conducted in Northwest Ethiopia in the Amhara Regional State, in which picture archiving and communication systems (PACS) usage was low in low- resourced countries. In relation to PACS, Open MRS was utilized in AHMC replacing paper work; however, paper usage was not fully abandoned throughout the facility. AURH uses both paper work and the system side-by-side in implemented units, as they cannot abandon paper work since it is not deployed in all units or departments. This finding also indicated that OpenMRS was not mature enough to be used universally. This finding is consistent with a previous finding that approximately 51.8% of respondents reported challenges accessing resources due to their young age groups of under 35 years (12,32). Furthermore, digital health presents promising opportunities in Oromia despite infrastructure constraints. Participants highlighted improved communication between providers, better tracking of patient information, enhancing decision-making capabilities, and referral systems as major gains. These findings align with studies in other Low and middle-income countries (LMICs), where digitalization has enabled more efficient data sharing, quicker clinical decision, faster diagnosis and enhanced continuity of care (9,33,34). Additionally, the presence of motivated health workers and an increasing interest in technology among younger professionals was seen as a positive sign or as a foundation for digital heath adoption for future digital uptake.\u003c/p\u003e\u003cp\u003eIn addition, other moderating variables or independent variables were facilitators included nongovernmental organization support, occasional government-led initiatives, and pilot programs introducing open medical record tools. The participants emphasized the importance of consistent technical assistance, reliable training, and organizational support. This aligns with the Unified Theory of Acceptance and Use of Technology, where facilitating conditions are crucial for adoption (35,36). Despite these favorable circumstances, numerous issues were noted, including erratic internet access, frequent power outages, a lack of digital infrastructure, poor training, a lack of technological know-how, and user resistance to change.\u003c/p\u003e\u003cp\u003eSimilar to previous studies conducted in Sub-Saharan Africa, these obstacles suggest systemic flaws that hinder the transformation of digital health World Health Organization (WHO), (37,38). Concerns about data privacy and unclear policy frameworks were also raised by participants. Additionally, the digitalization of e-learning platforms and decision- support technologies has helped alleviate the shortage of qualified healthcare workers in areas with insufficient resources (39). This enabled by virtual sessions organized through e-learning to offer various courses to enhance their abilities and expertise of various healthcare professionals (40). Similarly, the inadequacy of trained healthcare workers in treatment and diagnosis can be supported by an accurate Artificial Intelligence-based(AI-based) tool available to offer prompt decisions through decision support tools (41\u0026ndash;44). By gathering real-time data digitally, digitalization can monitor and control public health in dealing with communicable diseases and health catastrophes without endangering the public (45).Effective management of scarce medical supplies and equipment is essential in low-resource nations (46\u0026ndash;48)).However, digitalization can play a significant role in managing their supply chain through inventory management systems and remote health center support via Telehealth(49). Furthermore, a digital system allows for real-time tracking of medical equipment and supplies, ensuring their availability in stock, minimizing waste and monitoring drug expiration dates. It also help in identifying shortages early, thereby ensuring the timely delivery of important supplies (50\u0026ndash;52). Additionally, by utilizing digital tools, telehealth significantly reduces certain shortages (53). It offers the ability to request supplies, consult with experts online, and ensure important resources for delivering care are available.\u003c/p\u003e\u003cp\u003eIn adapting to these challenges, some participants with experience in digital systems found them useful, especially for reducing administrative burdens, improving patient tracking, and accelerating service delivery. These perceptions align with the Technology Acceptance Model (TAM), which emphasizes perceived usefulness as a key predictor of technology adoption (26,54).Some respondents who were not familiar with digital tools, however, were nonetheless skeptical of their usefulness.\u003c/p\u003e\u003cp\u003eUser-friendliness was a major consideration, especially for both older and technologically adept personnel. System deemed intuitive for digital health products featuring local language assistance have increased their engagement. On the other hand, the lack of a user-centered design was frequently mentioned as a barrier, which shown by previous research (55). This emphasizes the importance of digital health solutions aligning with users\u0026rsquo; cognitive and environmental realities. While several participants expressed a willingness to adopt digital tools, their actual intention depended on their prior experience, availability of support, and perceived relevance to those who believed the tools would directly improve their workflow. Behavioral intention was greater among those who believed that digital tools would ease their workload. Behavioral intention is shaped by both perceived usefulness and ease of use, according to the UTAUT and TAM frameworks (26,36,56).\u003c/p\u003e\u003cp\u003eMoreover, the actual system use was sporadic and often limited to pilot phases. Equipment failure, worker turnover, and lack of continuous training all hindered its sustainability. This emphasizes the gap between pilot performance and long-term adoption, as observed in the literature on global digital health by (27,57). The satisfactions of users are directly related to the availability of systems performance and support. When training was adequate and systems operated smoothly, participants expressed satisfaction. Dissatisfaction arose when tools were unreliable or when users felt unprepared to operate them. These findings reveal that satisfaction depends on both system reliability and user confidence (27,58,59). Those who had proper training and had operational mechanisms in place reported positive experiences. Others, especially those in remote areas with frequent system crashes, reported frustration. Reliability, assistance, and perceived personal benefits were strongly correlated with satisfaction.\u003c/p\u003e\u003cp\u003eHowever, these benefits were unevenly distributed and undermined by contextual barriers. Prior studies confirmed that digital health benefits are contingent on contextual fit and support infrastructure (60,61). It was context-dependent and aligns with the improved readiness and acceptance found in the study. Approximately 60% of health professionals show readiness in adopting EMRs if they are younger, skilled in using computers, digitally literate, and own their personal computer (62). These factors serve as predictors for EMR adoption. Furthermore, it enhances health data quality, retrievability, and traceability even through smartphones, enabling real-time documentation (13,63). This assists healthcare workers modernizing their efficiency of health management and making accountability stronger than traditional treatment. This also leads health executives and physicians to perceive digital systems as effective methods in reducing their workload and improving health service quality with the sufficient availability of devices and internet access being acknowledged (64).Chereka et al and Kasaye et al,, explained the net benefits that were aligned with participants thought in empowering digitalization through training and digital literacy. This boosted digital health literacy among professions, developed positive attitudes, perceived usefulness, and initiated training significantly (65,66). These factors motivated readiness and laid the groundwork for broad adoption throughout the region. The study highlights the benefits of digital systems in healthcare, including time savings, better coordination, and improved patient tracking. The study faces limitations including resource shortages, delayed data collection, oversampling of male healthcare professionals, and the use of qualitative methods, with only two hospitals selected from 114.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study emphasizes the need for a multi- stakeholder approach, including infrastructure investment, capacity building, user-centered design, and sustained policy commitment, to fully realize the potential of digital health in low-resource settings.\u003c/p\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eRecommendation\u003c/h2\u003e\u003cp\u003eThe author recommends further research on electronic health records, investigating data privacy concerns, and conducting a survey to alleviate patient reluctance about the digitalization of healthcare.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAHMC Adama Hospital Medical College\u003c/p\u003e\n\u003cp\u003eAI Artificial Intelligence\u003c/p\u003e\n\u003cp\u003eAURH Ambo University Referral Hospital\u003c/p\u003e\n\u003cp\u003eDM ISM DeLone and McLean Information Success Model\u003c/p\u003e\n\u003cp\u003eLIS Laboratory Information System\u003c/p\u003e\n\u003cp\u003eLMICs Low-and middle-income countries \u003c/p\u003e\n\u003cp\u003eOpenMRS Open Medical Record System\u003c/p\u003e\n\u003cp\u003ePACS Picture Archiving Communication Software\u003c/p\u003e\n\u003cp\u003eTAM Technology Acceptance Model\u003c/p\u003e\n\u003cp\u003eUTAUT Unified Technology Acceptance \u003c/p\u003e\n\u003cp\u003eW.H.O World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: \u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles outlined in the declaration of Helsinki (https://www.wma.net/policies-post/wma-declaration-of-helsinki/). The ethical approval was obtained from Jimma University, Institute of Technology under reference number (Ref. No: Comp/JiT/019/2015 E.C). Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eIn this study, consent for publication was not mandatory, as the study did not involve humans but rather focused on systems and how they operate when compared to manual methods.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe data supporting the finding of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eAll authors have no conflicts of interest on this manuscript.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eJimma University, Institute of Technology, AHMC, and Dar al Fiker Foundation were funded solely for the purpose of data collection.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eThe principal investigator designs, collects, analyzes, and writes up the manuscript. Authors Three and four also contribute to shaping the design strategies to best fit, constructing the analysis of the principal investigator\u0026rsquo;s ideas by adding their input, including comments or feedback. Author five to eight also contribute in design, data collection, transcribing the collected data, and writing the analysis focusing on methodology. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eI want to acknowledge those who have supported me financially and emotionally on this journey. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eStoumpos AI, Kitsios F, Talias MA. Digital Transformation in Healthcare: Technology Acceptance and Its Applications. IJERPH. 2023 Feb 15;20(4):3407. \u003c/li\u003e\n\u003cli\u003eSaeed SA, Masters RM. Disparities in Health Care and the Digital Divide. 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DIGITAL HEALTH. 2024 Jan;10:20552076241271799. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Supplementary Material","content":"\u003cp\u003eThe supplementary material file is not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Digitalization, healthcare, opportunities, challenges, Oromia","lastPublishedDoi":"10.21203/rs.3.rs-7528690/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7528690/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSeveral resource-limited countries around the world have benefited from the global advancement of technologies in various sectors, including healthcare by implementing digital solutions. One of these advancements in technology is the digitalization of healthcare through electronic medical records, which plays significant role in streamlining paper-work processes. This study aims to examine the opportunities and challenges of healthcare digitalization in low-resource settings, focusing on selected facilities in the Oromia Regional State of Ethiopia. Specifically, it explores how digital health initiatives such as electronic medical records and telemedicine affect service delivery, data management, and patient outcomes, while identifying barriers to their effective implementation. However, the adoption of digital healthcare systems in low-resource settings faces persistent challenges. These include the lack of sustainable government funding and heavy reliance on external donors, shortages of adequately trained healthcare professionals and, in some cases, resistance to adopting new technologies, the short-term and fragmented nature of many digital health initiatives, and the absence of advanced security mechanisms, particularly for remotely accessed systems that could leverage AI-based tools.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003ea qualitative approach that employed in-depth interviews and site observation in data collection from healthcare workers. MAXQDA version 2020 was used for thematic data analysis to create a pattern.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThis finding indicates that digitalization presents substantial opportunities for improving healthcare delivery in the selected facilities. The availability of supportive conditions has helped create an environment conducive to sustaining these initiatives. However, several challenges persist, many of which arise from gaps in fully realizing these opportunities and enabling conditions. Such challenges negatively influence perceived usefulness and perceived ease of use, ultimately shaping user behavior. Addressing these barriers is essential to ensuring consistent system adoption, user satisfaction, and the long-term sustainability of digital healthcare systems.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe study underscores the need for a comprehensive, the involvement of several participants to effective utilize digital health in low-resourced settings, addressing data privacy concerns and requiring robust policies.\u003c/p\u003e","manuscriptTitle":"Digitalization of healthcare in low-resourced settings: Opportunities and challenges, Qualitative study in Oromia, Ethiopia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 08:28:20","doi":"10.21203/rs.3.rs-7528690/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-01T15:39:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-28T09:27:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"306733213311626271182321879469533445263","date":"2025-11-21T14:27:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180681519141436522476845915674194222616","date":"2025-11-19T23:39:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176659711093625074319833483399940492469","date":"2025-11-03T14:49:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-02T13:38:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-28T07:50:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-16T06:53:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-13T23:03:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-09-13T23:00:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5fef090f-8985-498d-92df-de1e1278935e","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-02T13:53:22+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 08:28:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7528690","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7528690","identity":"rs-7528690","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}