Domains of Electronic Medical Records Quality in Global Health: Stakeholder Perspectives Using the STEEEP Framework

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Dunbar, Jen Antilla, Nancy Puttkammer, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6827804/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Many Low-and middle-income countries (LMICs) are moving rapidly to digitize the health sector, and health leaders need ways to evaluate the quality of available Electronic medical records (EMRs), to guide their investments. Yet EMR quality is an ill-defined concept and methods to operationalize assessment of EMR quality are also lacking. The study investigates domains that stakeholders in LMICs consider crucial to quality of EMRs using the STEEEP framework—Safety, Timeliness, Effectiveness, Efficiency, Equity, and Patient-centeredness. Materials and methods We conducted 27 individual semi structured virtual interviews across 14 countries with diverse stakeholders, including EMR builders, implementers, domain experts, and decision-makers, to explore the factors affecting EMR quality globally. We used deductive and inductive approaches to identify salient themes within the six STEEEP domains. Results Salient factors included technical, environmental, and human issues, with most stakeholders prioritizing effectiveness and efficiency. Effectiveness encompasses clinical decision support and data quality, whereas efficiency is related to cost, infrastructure, and training. Interoperability was identified as critical to safety and timeliness, whereas patient-centeredness and equity received limited attention. Discussion Stakeholder perceptions reveal the need for a multifaceted approach to ensure EMR quality, addressing gaps in patient-centeredness and equity—key principles of digital development. There is a need to sensitize stakeholders in these domains and integrate assessments into EMR evaluations, particularly in LMICs, to improve healthcare equity. Conclusion Our study highlights stakeholder perspectives on defining a practical framework for assessing EMR quality in LMICs, but further work is needed to operationalize the domains of patient-centeredness and equity. EMR quality STEEEP framework stakeholder perspective global health digital health Figures Figure 1 Figure 2 BACKGROUND Electronic medical records (EMRs) have become a pivotal component in digitizing healthcare, evolving significantly over the past few decades [ 1 , 2 , 3 ]. The potential of EMRs to revolutionize healthcare delivery and enhance patient outcomes is widely recognized [ 4 , 5 ]. Many low- and middle-income countries (LMICs) are moving rapidly to digitize the health sector, and health leaders need ways to evaluate the quality of available EMRs to guide their investments. However, EMR quality is an ill-defined concept, and methods for operationalizing the assessment of EMR quality are lacking. Stakeholders have varied perspectives on quality and are influenced by their roles within the healthcare ecosystem. EMR builders and implementers prioritize system reliability and interoperability [ 3 , 6 , 7 ], whereas decision makers focus more on the cost-effectiveness and sustainability of EMRs [ 8 , 9 ]. Moreover, healthcare providers and patients value ease of use, security, and the capacity for effective communication [ 10 , 11 , 12 , 13 , 14 ]. While healthcare quality has been extensively discussed and frameworks such as safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness (STEEEP) have been developed [ 15 ], there has been less focus on how to operationalize a definition of quality that can be used in judging EMRs and their role in healthcare [ 16 , 11 , 17 ]. This gap is particularly noticeable, as digital transformation in LMICs has occurred rapidly, often with limited resources and control over quality factors [ 18 , 19 ]. The complexity and diversity of stakeholder perspectives make the task of defining and measuring EMR quality a particularly challenging, yet increasingly crucial, task in today's healthcare landscape. SIGNIFICANCE The heterogeneity in EMR quality definitions has led to fragmented approaches in implementation and evaluation. Stakeholders often view quality through their own lenses—technical reliability for developers, cost-effectiveness for funders, and user-friendliness for healthcare providers and patients. The differing perspectives among stakeholders highlight the need for a multidimensional approach to defining and assessing EMR quality. OBJECTIVE This qualitative study explores the perspectives of individuals engaged with EMRs in LMICs, eliciting their insights into salient domains or dimensions of quality. Our goal was to align their insights with the domains of the STEEEP framework to broaden its applicability in judging EMRs in LMICs. MATERIALS AND METHODS The study was conducted at the University of Washington with support from the Digital Initiatives Group at I-TECH (DIGI) and the University of Washington School of Nursing. We conducted qualitative individual in-depth key informant interviews (KIIs) with experts on EMRs in LMICs. Participants were interviewed during the period of November 2022 - January 2023. Study participants were information technology professionals and organizational leaders working globally with EMRs and other digital health tools, categorized as 1) EMR builders and implementers, 2) decision-makers, and 3) domain experts (Table 2). Participants were selected using purposeful and snowball sampling for gender and professional balance. All were English-speaking and KIIs were conducted via Zoom with audio recording after verbal informed consent. Participants, based in or focused on LMICs, brought a deep understanding of these contexts, ensuring our exploration of EMR quality was grounded in LMIC realities. The semi-structured KIIs first explored participants' general opinions on the quality and trustworthiness of digital health tools, then focused specifically on EMRs in LMICs (Appendix 1). This approach allowed for broad insights into digital health quality, followed by specific input on defining and operationalizing EMR quality. Starting with a broader context helped to capture diverse experiences before diving into EMR-specific topics. Each interview started with questions about participants' background and roles to guide probes and to support interpretation. We conducted three pilot interviews to refine the questionnaire, using feedback to adjust before the main data collection. Transcripts were anonymized and assigned identification numbers, with pilot data excluding from the final analysis. We initially gathered open-ended stakeholder perceptions on how to define quality and how to operationalize the definition. This initial phase was crucial for capturing authentic views on quality from varied perspectives. Following this, applied the STEEEP framework, developed by the Institute of Medicine (Institute of Medicine, 2001), to assess the quality of EMRs across six domains: Safety, Timeliness, Effectiveness, Efficiency, Equity, and Patient-centeredness—to evaluate how these real-world insights correspond with established quality metrics. Furthermore, this process aimed to uncover any new domains of quality as indicated by stakeholders, potentially broadening the STEEEP framework's applicability. Employing this dual approach was essential for developing an inclusive definition of EMR quality that aligns with stakeholder expectations and fosters improved patient care. Using both deductive and inductive analysis, we structured our coding around the STEEEP domains while also identifying emergent themes from stakeholder perspectives on EMR quality (Table 1). To minimize bias, we did not introduce the STEEEP framework to respondents, who were unaware of its structure during the KIIs. After completing the interviews, we identified themes across all six STEEEP domains based on respondents' views on EMR quality (Table 3 and Table 3.1). Two researchers independently coded the transcriptions using a codebook based on the STEEEP domains, adding inductive codes for themes outside the framework. To ensure consistency, we regularly assessed the overlap and granularity, addressing discrepancies through discussion. This approach minimizes bias and ensures balanced coding. We quantified coded segments to assess theme prominence, providing clearer insights into stakeholder perspectives. Data analysis was conducted using Dedoose software (Dedoose, 2023). Ethical approval was obtained from the University of Washington's Human Subjects Division, categorizing the study as exempt (Study00016157). RESULTS Participant characteristics A total of 27 experts from 14 countries, 18 males and 9 females, participated in the KIIs (Table 1 ). They included EMR builders and implementers (59.3%), domain experts (18.5%), and decision-makers (22.2%). The participants’ experience levels varied: 11 had 1—4 years of experience, 7 had 5—8 years, and 8 had over 9 years. KIIs lasted from 18—51 minutes (mean = 38 minutes). Domains of quality from the perspective of stakeholders Safety In the STEEEP framework, "safety" is defined as "avoiding harm to patients from the care intended to help them." The participants emphasized that EMR systems must prioritize security, reliability, quality control, and privacy to protect patient data, reduce errors, and prevent unauthorized access. Safety was highlighted equally by all three stakeholder groups, comprising 8.2% of the coded segments from EMR builders and implementers, 8.7% from decision makers, and 9.7% from domain experts (Fig. 1 ). Stakeholders suggested complementary approaches to ensuring EMR safety. Builders and implementers emphasized the need for a clear data governance framework, including who should access and share data to protect patient confidentiality. Domain experts emphasized that EMRs must integrate seamlessly into clinical workflows to increase patient safety. Proper alignment with clinical processes reduces errors, ensures accurate data entry, and supports timely decision-making. They also highlighted the importance of strong data governance to maintain EMR quality, privacy, and security. Experts stressed the need for robust backup and recovery measures, especially in cloud-based solutions, to prevent data loss and preserve data completeness. Effective governance should start early in the implementation process, requiring consensus on data collection standards and privacy protocols: "Before an EMR should be built for the very first time, there needs to be a consensus on what you want to and what is agreed to collect: aspects of data, privacy, etc." (02). EMR builders and implementers emphasized the importance of data integrity and safety measures within workflows, whereas decision-makers focused on stakeholder engagement and capacity building for system adoption. One decision maker underscored the value of user-centric design: "When you build systems with users, you get better systems because they understand their workflows" (03). They also emphasized the importance of robust training and ongoing support services, noting that community involvement helps quickly identify and resolve issues: "An EMR supported by a community reduces the chances of problems" (03). While each stakeholder group focused on different aspects, data governance for builders, user training for decision-makers, and workflow integration for domain experts, all agreed that a multilayered approach was essential for ensuring both patient safety and data integrity in EMRs. Timeliness Timeliness-related themes were emphasized across all three stakeholder categories, accounting for 22.3% of the coded segments from EMR builders and implementers, 23.5% from decision-makers, and 20% from domain experts (Fig. 1 ). The IOM defines "timeliness" as "reducing unwanted waits and harmful delays for both recipients and providers of care. This domain encompasses prompt access to healthcare services, diagnostics, and treatments [ 20 ]. The participants emphasized that EMRs enhance timely clinical decision-making and streamline workflows. One EMR builder mentioned, "Health care workers should have what is convenient for them, facilitating the movement of information between providers and patients.” Speed in system response was emphasized, with one participant stating, “The response should be fast with almost no time lag between me and my patient" (02). Automation to reduce healthcare workers' wait times was also discussed: "A quality digital health tool should remove certain aspects of health care workers' wait time by automating those aspects" (02). Interoperability, which is crucial for timeliness, was another key theme. An EMR builder underscored the importance of integrated information: "Without it, you're losing time and continuity of care" (02). A domain expert added that interoperability depends on standardized data formats and secure data exchange. Overall, EMRs can improve timely healthcare by expediting clinical decision-making and ensuring rapid and secure data exchange, but this depends on system responsiveness, usability, and interoperability. With 22.3% of the coded segments among EMR builders and implementers focusing on "timeliness," our findings suggest the importance of this domain in EMR development and implementation (Fig. 1 ). Effectiveness The definition of “effectiveness” is “providing services on the basis of scientific knowledge to all who could benefit and refraining from providing services to those unlikely to benefit (that is, avoiding both overuse of inappropriate care and underuse of effective care)” [ 15 ]. It was the second most frequently mentioned domain, with EMR builders and implementers, decision-makers, and domain experts highlighting key factors such as data availability, accuracy, interoperability, and clinical decision support. For healthcare providers, accurate and complete data are critical for making effective clinical decisions. Data integrity was a key concern for EMR builders, with one participant stating, "Low-quality EMRs fail to generate useful data and reports for clinical purposes" (02). Domain experts emphasized the importance of scalability, noting that “effective systems should be able to accommodate multiple sites and large patient volumes” (03). In the effectiveness domain, EMR builders and implementers accounted for 32% of the coded segments, decision-makers accounted for 34%, and domain experts accounted for 26% (Fig. 1 ). Efficiency "Efficiency" refers to avoiding waste, including the misuse of resources, and leveraging existing resources to finance services. It was the most frequently referenced domain, with 27.2% of all coded segments focused on efficiency (Fig. 2 ). EMR builders, decision-makers, and domain experts referenced efficiency in 27.5%, 32.3%, and 37.7% of their responses, respectively (Fig. 1 ). The financial aspect of EMRs was a significant consideration, with stakeholders emphasizing the balance between robust system capabilities and affordability. One participant noted, "We want to ensure the system is well designed, with budgeting and funding within a cost that is not prohibitive for the country" (01). Equity Equity is defined as “Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, race, geographic location, and socioeconomic status” [ 15 ]. Few stakeholders have discussed the need for clear policies to manage patient data fairly within EMRs and ensure equitable access to healthcare services. Despite being in LMIC settings, equity was mentioned infrequently, with EMR builders and implementers discussing it in 3% of the responses, decision-makers in 0.7%, and domain experts in 2.9% (Fig. 1 ). Patient-centeredness “Patient-centeredness” refers to “providing care that is respectful of and responsive to individual preferences, needs, and values” [ 15 ]. This domain was one of the least discussed domains: EMR developers and implementers mentioned it in 7% of the responses, decision-makers in 1.3%, and domain experts in 3.4% (Fig. 1 ). The focus was on tailoring care to individual patient needs rather than following clinical protocols: “... this tool should be able to help him to collect and analyze data and make timely decisions” (02). One respondent emphasized that the tool should help healthcare providers better understand their patients and make timely decisions. Notably, 23.4% of those discussing this theme were from Zimbabwe, and 47% had 17—20 years of experience. This suggests that patient-centered care is valued but not equally prioritized across stakeholders or regions. Emergent themes for EMR quality. The STEEEP framework defines "what is quality?" by outlining its dimensions, but it does not explicitly address the critical aspects of implementation and quality assessment, which focus on "how to achieve quality." These two themes, although not part of the STEEEP, are essential for ensuring successful EMR adoption, usability, and healthcare outcomes: Streamlined EMR Implementation : Effective planning, leadership buy-in, adaptability, and documentation are vital for success. Stakeholders emphasized the importance of adaptable systems, trust-building, and the involvement of knowledgeable decision-makers. For example, one expert noted that adaptable technology minimizes technical adjustments, whereas another stressed the need for buy-in from policymakers to avoid governance issues. Hands-on experience also fosters trust: “You need to see it, touch it, and test it” (01). Proper planning is crucial, as poor planning often leads to system failure: “If you plan well the first time, most failures can be avoided” (02). EMR Quality Assessment : Continuous monitoring and evaluation ensure system performance. This includes tracking key performance indicators (KPIs), validating data quality, and aligning systems with user needs. Field visits often reveal discrepancies between EMR presentations and actual functionality: “You get great presentations, but on the ground, it’s a different story” (01). A domain expert highlighted the need for internal data checks and external validation for reliability. Process evaluations ensure that systems are stable, usable, and address real-world user needs. DISCUSSION Across each of the 6 STEEEP domains, the participants highlighted themes that are useful for defining EMR quality. Notably, EMR experts focused not only on technical aspects but also on how the EMR system interacts with its environment and workforce. This multifaceted perspective allowed us to consider how these diverse factors contribute to the overall quality of EMR systems. The study highlights how the STEEEP framework can effectively define the quality of EMRs, particularly in LMICs, providing operational ideas for assessment. Aligning EMRs with user needs and workflows has emerged as a key factor for enhancing utility and adoption. The study contributes to the literature by contextualizing the STEEEP framework in LMICs, bridging the gap between technical quality measures and practical healthcare outcomes. Unlike previous frameworks like Development of an Evaluation Framework for Health Information Systems (DIPSA Framework) [ 21 ], Health Information Technology Evaluation Framework (HITREF) [ 22 ], and Health Technology Assessment Framework for Digital Healthcare Services (DigiHTA) [ 23 ], the Institute of Medicine’s STEEEP criteria emerged as a comprehensive tool that encapsulates all six dimensions of quality, explicitly linking them to measurable improvements in healthcare outcomes [ 24 ]. Additionally, the framework has been pivotal in guiding measure development, merging technological advancements with patient care to foster improved health outcomes. Our findings are consistent with the Principles for Digital Development (PDD), a set of guiding principles endorsed by funders and implementers for digital health projects and systems. These principles, which include "Design with the User," "Understand the Existing Ecosystem," and "Build for Sustainability," emphasize the importance of developing user-centered, contextually aware, and long-term sustainable digital interventions​. Our findings align with these principles, as participants highlighted the critical need for EMR systems that not only meet technical standards but also align with clinical workflows and engage stakeholders throughout the development process. However, despite their relevance, operationalizing these principles in the field of digital health, especially when evaluating EMR quality, remains a significant challenge. The lack of specific tools or standardized benchmarks to assess EMRs against the PDD in LMIC contexts presents a gap in practice. Study participants recognized that defining EMR quality must be linked with methods for measuring quality and recommended the development of a standardized benchmarking tool to evaluate the quality of EMRs in LMICs, as a next step for operationalizing the application of the STEEEP framework in judging quality. Kang'a et al. [ 25 ] conducted a national assessment of EMR systems in Kenyan public health facilities guided by the country’s published standards for EMRs, but there has been limited other work of this type, highlighting the importance of standardized evaluation metrics to ensure functionality and usability​. Building on the insights from our study, a common benchmarking tool could help guide both self-assessment and formal certification processes, aligning with global standards and local needs. It would serve to evaluate various aspects of EMR quality—ranging from data integrity and interoperability to user satisfaction and safety—providing a consistent and objective framework for stakeholders. This approach can also help in identifying gaps in current systems, guiding improvement efforts, and supporting informed decision-making regarding EMR adoption and scaling across LMICs. In line with Dow's 2020 scoping review on evaluating hospitalist performance via the STEEEP framework [ 26 ], our participants frequently highlighted the domains of efficiency, effectiveness, and timeliness. The participants emphasized the importance of interoperability and clinical decision support in the domain of timeliness. These observations align with the emphasis on interoperability as a quality feature in several studies, such as those by Li [ 27 ], Zwaanswijkv [ 28 ], Dobrow [ 29 ]. Timeliness plays a pivotal role in patient outcomes [ 15 , 30 ]. All the stakeholder groups underscored safety, aligning with the literature on EMR safety and patient outcomes [ 4 ]. Workflow integration and usability testing were key themes, reflecting findings by Bowman [ 31 ] and Howe et al. [ 32 ]. In the effectiveness domain, data availability, quality, and user-centered design were highlighted, echoing concerns from Ehrenstein et al. [ 33 ] and Verma et al. [ 34 ] about the critical role of data quality. Discussions around efficiency were notably rich and focused on usability and cost, supporting Pruitt's [ 35 ] and Modi's [ 36 ] findings on usability and financial implications. The Institute of Medicine defines patient-centeredness as care that respects and responds to individual preferences, needs, and values, guiding clinical decisions, especially during care transitions. Only a few participants focused on patient-centeredness, which contrasts with the emphasis placed on this domain in the studies by Butler et al. [ 37 ] and Brands et al. [ 38 ]. This discrepancy calls for further investigation into how EMR systems can better support patient-centered care. EMRs can become patient-centered and enhance healthcare by including patient-reported outcomes, thus improving the representativeness and completeness of health records [ 39 ]. Training programs for providers have been shown to facilitate more patient-sensitive interactions [ 40 ] and could be adapted or extended to address how to provide patient-sensitive interactions in the context of using EMRs while providing care, whereas user-centered design can ensure that the system aligns with patients' values [ 41 ]. Access to health information can empower patients, encouraging active participation in their care, and efforts can be made to ensure that EMRs are accessible to all, particularly marginalized, groups [ 42 ]. Balancing transparency with privacy is essential in maintaining a supportive patient‒clinician relationship and personalizing the healthcare experience. Equity has received less attention, confirming Dow's view of equity as the "forgotten aim" of the STEEEP framework and suggesting a gap for further research, as noted by Penman-Aguilar [ 43 ]. The literature also highlights challenges in achieving health equity through EMRs, such as biases in data affecting underserved populations [ 44 , 45 ] and ethical concerns about patient care and physician‒patient relationships [ 46 ]. Our research addresses this gap by identifying salient elements of EMR quality and integrating these insights within the STEEEP framework. While domains such as efficiency and effectiveness confirmed known themes, the low prioritization of patient-centeredness and equity by stakeholders—despite their centrality in global digital health principles—represents a novel and critical finding that warrants further exploration. In addition to the STEEEP framework, our study emphasizes two critical areas often underexplored in the literature: EMR implementation and quality assessment. Responders reinforce the importance of these aspects, which aligns with the literature on effective implementation practices and ongoing evaluation. Rizer et al. [ 47 ] highlighted the significance of leadership, training, support, and system optimization, whereas Donnelly et al. [ 48 ] stressed the importance of assessing data reliability and the role of EMRs in quality measurement. Both studies highlight the potential of EMRs to reduce data collection burdens, although further research is needed to expand their implementation. By focusing on both the "how" of EMR implementation and the role of continuous quality assessment , these findings offer a more holistic approach to improving EMR systems. This not only enhances the functionality of the systems but also ensures that they effectively support healthcare professionals in providing high-quality, patient-centered care. Ultimately, insights from EMR assessment grounded in the STEEEP framework and the use of standardized measurement tools and procedures have the potential to drive more efficient, accurate, and accessible healthcare, leading to better health outcomes. Strengths and Limitations The study has multiple strengths, including a diverse sample of stakeholders from 14 countries, enriching the findings with various perspectives, experiences, and contextual factors. Additionally, the study benefits from a substantial sample size of 3 pilot interviews and 27 main KIIs, ensuring thematic saturation. The involvement of participants from various stakeholder groups enhances the research's relevance and applicability, while the study's findings hold potential for guiding future investigations. The participants were initially invited through the study team's global network, supplemented by snowball sampling, to expand the participant pool. Despite the unequal distribution of participants across categories, with EMR builders and implementers numbering 16, domain experts 5, and decision makers 6, our study included enough participants from each group. A limitation of the study is that the majority of our participants were from African countries, which could limit the transferability of our findings to other regions of the world. This concentration can be explained by the fact that the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has invested strongly in scaling EMRs for HIV treatment programs in LMICs, especially in the African region. This means that the findings may not be fully representative of the entire population and may not provide a complete understanding of the research question. CONCLUSION Our study reveals the perspectives of stakeholders regarding EMR quality, highlighting the significance of clinical decision support, data quality, and stakeholder engagement. Effectiveness and efficiency were identified as the most frequently discussed domains. Notably, patient-centeredness and equity received less focus, indicating domains that require further research. Implications for Healthcare Quality: Effectiveness and efficiency: EMRs should prioritize decision support and data quality while addressing cost and training needs. Enhancing interoperability should be a key goal, facilitating seamless data exchange to improve healthcare delivery. Patient-centeredness: The gap in this area calls for a focus on design principles that cater to patient needs and preferences. Equity: The observed lack of focus on equity suggests a need for targeted research to promote equitable access and outcomes. These insights offer a roadmap for healthcare organizations and policymakers to improve EMR quality and implementation effectively. Abbreviations EMR – Electronic Medical Record HIS – Health Information System LMIC – Low- and Middle-Income Country KIIs – Key Informant Interviews STEEEP – Safety, Timeliness, Effectiveness, Efficiency, Equity, and Patient-centeredness PDD – Principles for Digital Development PEPFAR – President's Emergency Plan for AIDS Relief Declarations Ethics approval and consent to participate. This study was reviewed and approved by the University of Washington's Human Subjects Division (Study00016157) and was categorized as exempt. All research procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Verbal informed consent was obtained from all individual participants prior to their inclusion in the study. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to privacy restrictions but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was conducted as part of a student master’s thesis at the University of Washington and did not receive external funding. Authors’ contributions AS designed the study, conducted interviews, performed data analysis, and led manuscript writing. All authors read and approved the final manuscript. Acknowledgements We would like to express our sincere gratitude to all the participants who participated in this study. We also acknowledge the invaluable contributions of the DIGI team members. 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JMIR Med Inf. 2019;7(2):e12607. Hannawa AF, Wu AW, Kolyada A, Potemkina A, Donaldson LJ. The Aspects of Healthcare Quality That Are Important to Health Professionals and patients: a Qualitative Study. Patient Educ Couns. 2022;105(6):1561–70. Bowman S. Impact of electronic health record systems on information integrity: quality and safety implications. Perspectives in Health Information Management [Internet]. 2013;10:1c. Available from: https://pubmed.ncbi.nlm.nih.gov/24159271/ Howe JL, Adams KT, Hettinger AZ, Ratwani RM. Electronic Health Record Usability Issues and Potential Contribution to Patient Harm. JAMA [Internet]. 2018;319(12):1276. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885839/ Ehrenstein V, Kharrazi H, Lehmann H, Taylor CO. Obtaining Data From Electronic Health Records [Internet]. . Agency for Healthcare Research and Quality (US); 2019. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551878 Verma N, Mamlin B, Flowers J, Acharya S, Labrique A, Cullen T. OpenMRS as a global good: Impact, opportunities, challenges, and lessons learned from fifteen years of implementation. Int J Med Informatics. 2021;149:104405. Pruitt ZM, Howe JL, Hettinger AZ, Ratwani RM. Emergency Physician Perceptions of Electronic Health Record Usability and Safety. J Patient Saf. 2021;Publish Ahead of Print. Modi S, Feldman SS. The Value of Electronic Health Records Since the Health Information Technology for Economic and Clinical Health Act: Systematic Review. JMIR Med Inf. 2022;10(9):e37283. Butler JM, Gibson B, Lewis L, Reiber G, Kramer H, Rupper R, et al. Patient-centered care and the electronic health record: Exploring functionality and gaps. J Am Med Inf Association Open. 2020;3(3):360–8. Brands MR, Gouw SC, Beestrum M, Cronin RM, Fijnvandraat K, Badawy SM. Patient-Centered Digital Health Records and Their Effects on Health Outcomes: Systematic Review. J Med Internet Res. 2022;24(12). Chung AE, Basch EM. Incorporating the patient’s voice into electronic health records through patient-reported outcomes as the review of systems. J Am Med Inform Assoc. 2015;22(4):914–6. Lanier C, Dominicé Dao M, Hudelson P, Cerutti B, Junod Perron N. Learning to use electronic health records: can we stay patient-centered? A pre-post intervention study with family medicine residents. BMC Fam Pract. 2017;18(1). Michael CL, Mittelstaedt H, Chen Y, Desai AV, Kuperman GJ. Applying User-Centered Design in the Electronic Health Record (EHR) to Facilitate Patient-Centered Care in Oncology. AMIA Annual Symposium proceedings AMIA Symposium [Internet]. 2021;2020:833–9. Available from: https://pubmed.ncbi.nlm.nih.gov/33936458/ Sham S, Shiwlani S, Kumar SK, Bai P, Bendari A. Empowering Patients Through Digital Health Literacy and Access to Electronic Medical Records (EMRs) in the Developing World. Curēus. 2024. Penman-Aguilar A, Talih M, Huang D, Moonesinghe R, Bouye K, Beckles G. Measurement of Health Disparities, Health Inequities, and Social Determinants of Health to Support the Advancement of Health Equity. Journal of Public Health Management and Practice [Internet]. 2016;22(1):S33–42. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5845853/ Acholonu RG, Raphael JL. The Influence of the Electronic Health Record on Achieving Equity and Eliminating Health Disparities for Children. Pediatr Ann. 2022;51(3). Boyd AD, Gonzalez-Guarda R, Lawrence K, Patil CL, Ezenwa MO, O’Brien EC et al. Equity and bias in electronic health records data. Contemporary Clinical Trials [Internet]. 2023;130:107238. Available from: https://www.sciencedirect.com/science/article/pii/S1551714423001611 Sulmasy LS, López AM, Horwitch CA. Ethical Implications of the Electronic Health Record: In the Service of the Patient. Journal of General Internal Medicine [Internet]. 2017;32(8):935–9. Available from: https://pubmed.ncbi.nlm.nih.gov/28321550/ Rizer MK, Kaufman B, Sieck CJ, Hefner JL, McAlearney AS. Top 10 Lessons Learned from Electronic Medical Record Implementation in a Large Academic Medical Center. Perspectives in health information management [Internet]. 2015;12(Summer):1 g. Available from: https://pubmed.ncbi.nlm.nih.gov/26396558/ Donnelly C, Janssen A, Vinod S, Stone E, Harnett P, Shaw T. A Systematic Review of Electronic Medical Record Driven Quality Measurement and Feedback Systems. Int J Environ Res Public Health. 2022;20(1):200. Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6827804","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":471564728,"identity":"ff6cac86-67a6-4fff-a85e-78ea6e92e10b","order_by":0,"name":"Assem Suleimenova","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABIElEQVRIiWNgGAWjYDCCAyCigIEHyv1fv/94A5A2sCCgxQCuhZmx4QxIyECCoBYYAGq5kQBi4NbCd/sA82ceAxsZ3fbeg495atiYGWc+v7rhR4EEA397dwI2LZLnEtikeQzSeMzOnEs25jnGw8YsnVN2swfoMIkzZzdg02JwhoGNmcfgMI/ZjRwzyRlsEjxs0jlpN3iAWgwkcnFpATnsP4/Z/TdALf8MJHgkz6Td/INfCwPQYQeAtvCYSXxsSzCQkGA/dhufLZJnGNsk5xgkA/2SY2zwse9AggFPDtttGaBtuPzCd4b58Ic3FXb2ZsfPGD5I+AbUwn782c03f2zk+Nt7sWphYGBsQBfhAUcTD4ZKPID9ASmqR8EoGAWjYPgDAHZzXapR+YM+AAAAAElFTkSuQmCC","orcid":"","institution":"University of Washington","correspondingAuthor":true,"prefix":"","firstName":"Assem","middleName":"","lastName":"Suleimenova","suffix":""},{"id":471564729,"identity":"31eda5a6-da47-488a-b43b-a1ef3abd6cbf","order_by":1,"name":"Elizabeth L. Dunbar","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"L.","lastName":"Dunbar","suffix":""},{"id":471564730,"identity":"408a0581-388c-4001-84be-1f98976f914a","order_by":2,"name":"Jen Antilla","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Jen","middleName":"","lastName":"Antilla","suffix":""},{"id":471564731,"identity":"c3b6b3be-dae1-439c-ae52-1be8449c4fa4","order_by":3,"name":"Nancy Puttkammer","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Nancy","middleName":"","lastName":"Puttkammer","suffix":""},{"id":471564732,"identity":"855b71a4-9040-46a9-91d6-b25db91a61cf","order_by":4,"name":"Meg Moldestad","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Meg","middleName":"","lastName":"Moldestad","suffix":""},{"id":471564733,"identity":"ff81e31b-3d77-412e-8b89-ecede4596949","order_by":5,"name":"Jan Flowers","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Jan","middleName":"","lastName":"Flowers","suffix":""}],"badges":[],"createdAt":"2025-06-05 09:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6827804/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6827804/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84872576,"identity":"188eb86b-b4f3-4dd4-a06f-937685274c2b","added_by":"auto","created_at":"2025-06-18 09:15:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":76017,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe percentage of coded segments belonging to any of the six domains is identified by the stakeholder groups.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEMR B\u0026amp;I - \u003c/strong\u003eEMR builder and implementer\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDM - \u003c/strong\u003eDecision maker\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDE - \u003c/strong\u003eDomain expert\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6827804/v1/94bc7acc4fcc5ae322460d21.png"},{"id":84872577,"identity":"65fca9fe-adc2-446b-a211-2e658a43c7b9","added_by":"auto","created_at":"2025-06-18 09:15:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":68042,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePercentage of all coded segments allocated to each domain.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e*Other aspects: EMR implementation and quality assessment\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6827804/v1/eb9457f0df3e27f0f60d837a.png"},{"id":84875576,"identity":"40f48bcb-4a41-415c-9973-ee69bdaac434","added_by":"auto","created_at":"2025-06-18 09:39:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":795484,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6827804/v1/ce935eba-d29a-4fff-85be-3bf5fe043ef9.pdf"},{"id":84872583,"identity":"df4cacf0-e4c7-4698-a59d-febfda915557","added_by":"auto","created_at":"2025-06-18 09:15:04","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":2148651,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryfileAppendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-6827804/v1/2fd0b160587bfb203f972443.docx"},{"id":84872578,"identity":"39b9b776-6cfd-4460-91ad-b3ecb11cf52c","added_by":"auto","created_at":"2025-06-18 09:15:04","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":23870,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6827804/v1/db03fac6b99c33ff497888d4.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Domains of Electronic Medical Records Quality in Global Health: Stakeholder Perspectives Using the STEEEP Framework","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eElectronic medical records (EMRs) have become a pivotal component in digitizing healthcare, evolving significantly over the past few decades [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The potential of EMRs to revolutionize healthcare delivery and enhance patient outcomes is widely recognized [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Many low- and middle-income countries (LMICs) are moving rapidly to digitize the health sector, and health leaders need ways to evaluate the quality of available EMRs to guide their investments. However, EMR quality is an ill-defined concept, and methods for operationalizing the assessment of EMR quality are lacking.\u003c/p\u003e \u003cp\u003eStakeholders have varied perspectives on quality and are influenced by their roles within the healthcare ecosystem. EMR builders and implementers prioritize system reliability and interoperability [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], whereas decision makers focus more on the cost-effectiveness and sustainability of EMRs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Moreover, healthcare providers and patients value ease of use, security, and the capacity for effective communication [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile healthcare quality has been extensively discussed and frameworks such as safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness (STEEEP) have been developed [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], there has been less focus on how to operationalize a definition of quality that can be used in judging EMRs and their role in healthcare [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This gap is particularly noticeable, as digital transformation in LMICs has occurred rapidly, often with limited resources and control over quality factors [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe complexity and diversity of stakeholder perspectives make the task of defining and measuring EMR quality a particularly challenging, yet increasingly crucial, task in today's healthcare landscape.\u003c/p\u003e\n\u003ch3\u003eSIGNIFICANCE\u003c/h3\u003e\n\u003cp\u003eThe heterogeneity in EMR quality definitions has led to fragmented approaches in implementation and evaluation. Stakeholders often view quality through their own lenses\u0026mdash;technical reliability for developers, cost-effectiveness for funders, and user-friendliness for healthcare providers and patients. The differing perspectives among stakeholders highlight the need for a multidimensional approach to defining and assessing EMR quality.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eOBJECTIVE\u003c/h2\u003e \u003cp\u003eThis qualitative study explores the perspectives of individuals engaged with EMRs in LMICs, eliciting their insights into salient domains or dimensions of quality. Our goal was to align their insights with the domains of the STEEEP framework to broaden its applicability in judging EMRs in LMICs.\u003c/p\u003e \u003c/div\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eThe study was conducted at the University of Washington with support from the Digital Initiatives Group at I-TECH (DIGI) and the University of Washington School of Nursing. We conducted qualitative individual in-depth key informant interviews (KIIs) with experts on EMRs in LMICs. Participants were interviewed during the period of November 2022 - January 2023.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStudy participants were information technology professionals and organizational leaders working globally with EMRs and other digital health tools, categorized as 1) EMR builders and implementers, 2) decision-makers, and 3) domain experts (Table 2).\u0026nbsp;Participants were selected using purposeful and snowball sampling for gender and professional balance. All were English-speaking and KIIs were conducted via Zoom with audio recording after verbal informed consent. Participants, based in or focused on LMICs, brought a deep understanding of these contexts, ensuring our exploration of EMR quality was grounded in LMIC realities.\u003c/p\u003e\n\u003cp\u003eThe semi-structured KIIs first explored participants' general opinions on the quality and trustworthiness of digital health tools, then focused specifically on EMRs in LMICs (Appendix 1). This approach allowed for broad insights into digital health quality, followed by specific input on defining and operationalizing EMR quality. Starting with a broader context helped to capture diverse experiences before diving into EMR-specific topics. Each interview started with questions about participants' background and roles to guide probes and to support interpretation. We conducted three pilot interviews to refine the questionnaire, using feedback to adjust before the main data collection. Transcripts were anonymized and assigned identification numbers, with pilot data excluding from the final analysis.\u003c/p\u003e\n\u003cp\u003eWe initially gathered open-ended stakeholder perceptions on how to define quality and how to operationalize the definition. This initial phase was crucial for capturing authentic views on quality from varied perspectives. Following this, applied the STEEEP framework, developed by the Institute of Medicine (Institute of Medicine, 2001), to assess the quality of EMRs across six domains: Safety, Timeliness, Effectiveness, Efficiency, Equity, and Patient-centeredness—to evaluate how these real-world insights correspond with established quality metrics. Furthermore, this process aimed to uncover any new domains of quality as indicated by stakeholders, potentially broadening the STEEEP framework's applicability. Employing this dual approach was essential for developing an inclusive definition of EMR quality that aligns with stakeholder expectations and fosters improved patient care. Using both deductive and inductive analysis, we structured our coding around the STEEEP domains while also identifying emergent themes from stakeholder perspectives on EMR quality (Table 1). To minimize bias, we did not introduce the STEEEP framework to respondents, who were unaware of its structure during the KIIs. After completing the interviews, we identified themes across all six STEEEP domains based on respondents' views on EMR quality (Table 3 and Table 3.1). Two researchers independently coded the transcriptions using a codebook based on the STEEEP domains, adding inductive codes for themes outside the framework. To ensure consistency, we regularly assessed the overlap and granularity, addressing discrepancies through discussion. This approach minimizes bias and ensures balanced coding. We quantified coded segments to assess theme prominence, providing clearer insights into stakeholder perspectives. Data analysis was conducted using Dedoose software (Dedoose, 2023). Ethical approval was obtained from the University of Washington's Human Subjects Division, categorizing the study as exempt (Study00016157).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eA total of 27 experts from 14 countries, 18 males and 9 females, participated in the KIIs (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). They included EMR builders and implementers (59.3%), domain experts (18.5%), and decision-makers (22.2%). The participants\u0026rsquo; experience levels varied: 11 had 1\u0026mdash;4 years of experience, 7 had 5\u0026mdash;8 years, and 8 had over 9 years. KIIs lasted from 18\u0026mdash;51 minutes (mean\u0026thinsp;=\u0026thinsp;38 minutes).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDomains of quality from the perspective of stakeholders\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSafety\u003c/h2\u003e \u003cp\u003eIn the STEEEP framework, \"safety\" is defined as \"avoiding harm to patients from the care intended to help them.\" The participants emphasized that EMR systems must prioritize security, reliability, quality control, and privacy to protect patient data, reduce errors, and prevent unauthorized access. Safety was highlighted equally by all three stakeholder groups, comprising 8.2% of the coded segments from EMR builders and implementers, 8.7% from decision makers, and 9.7% from domain experts (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Stakeholders suggested complementary approaches to ensuring EMR safety. Builders and implementers emphasized the need for a clear data governance framework, including who should access and share data to protect patient confidentiality.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDomain experts emphasized that EMRs must integrate seamlessly into clinical workflows to increase patient safety. Proper alignment with clinical processes reduces errors, ensures accurate data entry, and supports timely decision-making. They also highlighted the importance of strong data governance to maintain EMR quality, privacy, and security. Experts stressed the need for robust backup and recovery measures, especially in cloud-based solutions, to prevent data loss and preserve data completeness. Effective governance should start early in the implementation process, requiring consensus on data collection standards and privacy protocols: \"Before an EMR should be built for the very first time, there needs to be a consensus on what you want to and what is agreed to collect: aspects of data, privacy, etc.\" (02).\u003c/p\u003e \u003cp\u003eEMR builders and implementers emphasized the importance of data integrity and safety measures within workflows, whereas decision-makers focused on stakeholder engagement and capacity building for system adoption. One decision maker underscored the value of user-centric design: \"When you build systems with users, you get better systems because they understand their workflows\" (03). They also emphasized the importance of robust training and ongoing support services, noting that community involvement helps quickly identify and resolve issues: \"An EMR supported by a community reduces the chances of problems\" (03).\u003c/p\u003e \u003cp\u003eWhile each stakeholder group focused on different aspects, data governance for builders, user training for decision-makers, and workflow integration for domain experts, all agreed that a multilayered approach was essential for ensuring both patient safety and data integrity in EMRs.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTimeliness\u003c/h3\u003e\n\u003cp\u003eTimeliness-related themes were emphasized across all three stakeholder categories, accounting for 22.3% of the coded segments from EMR builders and implementers, 23.5% from decision-makers, and 20% from domain experts (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe IOM defines \"timeliness\" as \"reducing unwanted waits and harmful delays for both recipients and providers of care. This domain encompasses prompt access to healthcare services, diagnostics, and treatments [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe participants emphasized that EMRs enhance timely clinical decision-making and streamline workflows. One EMR builder mentioned, \"Health care workers should have what is convenient for them, facilitating the movement of information between providers and patients.\u0026rdquo; Speed in system response was emphasized, with one participant stating, \u0026ldquo;The response should be fast with almost no time lag between me and my patient\" (02). Automation to reduce healthcare workers' wait times was also discussed: \"A quality digital health tool should remove certain aspects of health care workers' wait time by automating those aspects\" (02).\u003c/p\u003e \u003cp\u003eInteroperability, which is crucial for timeliness, was another key theme. An EMR builder underscored the importance of integrated information: \"Without it, you're losing time and continuity of care\" (02). A domain expert added that interoperability depends on standardized data formats and secure data exchange.\u003c/p\u003e \u003cp\u003eOverall, EMRs can improve timely healthcare by expediting clinical decision-making and ensuring rapid and secure data exchange, but this depends on system responsiveness, usability, and interoperability. With 22.3% of the coded segments among EMR builders and implementers focusing on \"timeliness,\" our findings suggest the importance of this domain in EMR development and implementation (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eEffectiveness\u003c/h3\u003e\n\u003cp\u003eThe definition of \u0026ldquo;effectiveness\u0026rdquo; is \u0026ldquo;providing services on the basis of scientific knowledge to all who could benefit and refraining from providing services to those unlikely to benefit (that is, avoiding both overuse of inappropriate care and underuse of effective care)\u0026rdquo; [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. It was the second most frequently mentioned domain, with EMR builders and implementers, decision-makers, and domain experts highlighting key factors such as data availability, accuracy, interoperability, and clinical decision support.\u003c/p\u003e \u003cp\u003eFor healthcare providers, accurate and complete data are critical for making effective clinical decisions. Data integrity was a key concern for EMR builders, with one participant stating, \"Low-quality EMRs fail to generate useful data and reports for clinical purposes\" (02). Domain experts emphasized the importance of scalability, noting that \u0026ldquo;effective systems should be able to accommodate multiple sites and large patient volumes\u0026rdquo; (03).\u003c/p\u003e \u003cp\u003eIn the effectiveness domain, EMR builders and implementers accounted for 32% of the coded segments, decision-makers accounted for 34%, and domain experts accounted for 26% (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEfficiency\u003c/h2\u003e \u003cp\u003e\"Efficiency\" refers to avoiding waste, including the misuse of resources, and leveraging existing resources to finance services. It was the most frequently referenced domain, with 27.2% of all coded segments focused on efficiency (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). EMR builders, decision-makers, and domain experts referenced efficiency in 27.5%, 32.3%, and 37.7% of their responses, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe financial aspect of EMRs was a significant consideration, with stakeholders emphasizing the balance between robust system capabilities and affordability. One participant noted, \"We want to ensure the system is well designed, with budgeting and funding within a cost that is not prohibitive for the country\" (01).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEquity\u003c/h2\u003e \u003cp\u003eEquity is defined as \u0026ldquo;Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, race, geographic location, and socioeconomic status\u0026rdquo; [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Few stakeholders have discussed the need for clear policies to manage patient data fairly within EMRs and ensure equitable access to healthcare services. Despite being in LMIC settings, equity was mentioned infrequently, with EMR builders and implementers discussing it in 3% of the responses, decision-makers in 0.7%, and domain experts in 2.9% (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePatient-centeredness\u003c/h2\u003e \u003cp\u003e\u0026ldquo;Patient-centeredness\u0026rdquo; refers to \u0026ldquo;providing care that is respectful of and responsive to individual preferences, needs, and values\u0026rdquo; [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This domain was one of the least discussed domains: EMR developers and implementers mentioned it in 7% of the responses, decision-makers in 1.3%, and domain experts in 3.4% (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The focus was on tailoring care to individual patient needs rather than following clinical protocols: \u0026ldquo;... this tool should be able to help him to collect and analyze data and make timely decisions\u0026rdquo; (02). One respondent emphasized that the tool should help healthcare providers better understand their patients and make timely decisions. Notably, 23.4% of those discussing this theme were from Zimbabwe, and 47% had 17\u0026mdash;20 years of experience. This suggests that patient-centered care is valued but not equally prioritized across stakeholders or regions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEmergent themes for EMR quality.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe STEEEP framework defines \"what is quality?\" by outlining its dimensions, but it does not explicitly address the critical aspects of implementation and quality assessment, which focus on \"how to achieve quality.\" These two themes, although not part of the STEEEP, are essential for ensuring successful EMR adoption, usability, and healthcare outcomes:\u003c/p\u003e \u003cp\u003e \u003cem\u003eStreamlined EMR Implementation\u003c/em\u003e: Effective planning, leadership buy-in, adaptability, and documentation are vital for success. Stakeholders emphasized the importance of adaptable systems, trust-building, and the involvement of knowledgeable decision-makers. For example, one expert noted that adaptable technology minimizes technical adjustments, whereas another stressed the need for buy-in from policymakers to avoid governance issues. Hands-on experience also fosters trust: \u0026ldquo;You need to see it, touch it, and test it\u0026rdquo; (01). Proper planning is crucial, as poor planning often leads to system failure: \u0026ldquo;If you plan well the first time, most failures can be avoided\u0026rdquo; (02).\u003c/p\u003e \u003cp\u003e \u003cem\u003eEMR Quality Assessment\u003c/em\u003e: Continuous monitoring and evaluation ensure system performance. This includes tracking key performance indicators (KPIs), validating data quality, and aligning systems with user needs. Field visits often reveal discrepancies between EMR presentations and actual functionality: \u0026ldquo;You get great presentations, but on the ground, it\u0026rsquo;s a different story\u0026rdquo; (01). A domain expert highlighted the need for internal data checks and external validation for reliability. Process evaluations ensure that systems are stable, usable, and address real-world user needs.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAcross each of the 6 STEEEP domains, the participants highlighted themes that are useful for defining EMR quality. Notably, EMR experts focused not only on technical aspects but also on how the EMR system interacts with its environment and workforce. This multifaceted perspective allowed us to consider how these diverse factors contribute to the overall quality of EMR systems. The study highlights how the STEEEP framework can effectively define the quality of EMRs, particularly in LMICs, providing operational ideas for assessment. Aligning EMRs with user needs and workflows has emerged as a key factor for enhancing utility and adoption.\u003c/p\u003e \u003cp\u003eThe study contributes to the literature by contextualizing the STEEEP framework in LMICs, bridging the gap between technical quality measures and practical healthcare outcomes. Unlike previous frameworks like Development of an Evaluation Framework for Health Information Systems (DIPSA Framework) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], Health Information Technology Evaluation Framework (HITREF) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and Health Technology Assessment Framework for Digital Healthcare Services (DigiHTA) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], the Institute of Medicine\u0026rsquo;s STEEEP criteria emerged as a comprehensive tool that encapsulates all six dimensions of quality, explicitly linking them to measurable improvements in healthcare outcomes [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Additionally, the framework has been pivotal in guiding measure development, merging technological advancements with patient care to foster improved health outcomes.\u003c/p\u003e \u003cp\u003eOur findings are consistent with the Principles for Digital Development (PDD), a set of guiding principles endorsed by funders and implementers for digital health projects and systems. These principles, which include \"Design with the User,\" \"Understand the Existing Ecosystem,\" and \"Build for Sustainability,\" emphasize the importance of developing user-centered, contextually aware, and long-term sustainable digital interventions​. Our findings align with these principles, as participants highlighted the critical need for EMR systems that not only meet technical standards but also align with clinical workflows and engage stakeholders throughout the development process. However, despite their relevance, operationalizing these principles in the field of digital health, especially when evaluating EMR quality, remains a significant challenge. The lack of specific tools or standardized benchmarks to assess EMRs against the PDD in LMIC contexts presents a gap in practice. Study participants recognized that defining EMR quality must be linked with methods for measuring quality and recommended the development of a standardized benchmarking tool to evaluate the quality of EMRs in LMICs, as a next step for operationalizing the application of the STEEEP framework in judging quality. Kang'a et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] conducted a national assessment of EMR systems in Kenyan public health facilities guided by the country\u0026rsquo;s published standards for EMRs, but there has been limited other work of this type, highlighting the importance of standardized evaluation metrics to ensure functionality and usability​. Building on the insights from our study, a common benchmarking tool could help guide both self-assessment and formal certification processes, aligning with global standards and local needs. It would serve to evaluate various aspects of EMR quality\u0026mdash;ranging from data integrity and interoperability to user satisfaction and safety\u0026mdash;providing a consistent and objective framework for stakeholders. This approach can also help in identifying gaps in current systems, guiding improvement efforts, and supporting informed decision-making regarding EMR adoption and scaling across LMICs.\u003c/p\u003e \u003cp\u003eIn line with Dow's 2020 scoping review on evaluating hospitalist performance via the STEEEP framework [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], our participants frequently highlighted the domains of efficiency, effectiveness, and timeliness. The participants emphasized the importance of interoperability and clinical decision support in the domain of timeliness. These observations align with the emphasis on interoperability as a quality feature in several studies, such as those by Li [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], Zwaanswijkv [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], Dobrow [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Timeliness plays a pivotal role in patient outcomes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. All the stakeholder groups underscored safety, aligning with the literature on EMR safety and patient outcomes [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Workflow integration and usability testing were key themes, reflecting findings by Bowman [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and Howe et al. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In the effectiveness domain, data availability, quality, and user-centered design were highlighted, echoing concerns from Ehrenstein et al. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and Verma et al. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] about the critical role of data quality. Discussions around efficiency were notably rich and focused on usability and cost, supporting Pruitt's [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] and Modi's [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] findings on usability and financial implications.\u003c/p\u003e \u003cp\u003eThe Institute of Medicine defines patient-centeredness as care that respects and responds to individual preferences, needs, and values, guiding clinical decisions, especially during care transitions. Only a few participants focused on patient-centeredness, which contrasts with the emphasis placed on this domain in the studies by Butler et al. [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] and Brands et al. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This discrepancy calls for further investigation into how EMR systems can better support patient-centered care. EMRs can become patient-centered and enhance healthcare by including patient-reported outcomes, thus improving the representativeness and completeness of health records [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Training programs for providers have been shown to facilitate more patient-sensitive interactions [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] and could be adapted or extended to address how to provide patient-sensitive interactions in the context of using EMRs while providing care, whereas user-centered design can ensure that the system aligns with patients' values [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Access to health information can empower patients, encouraging active participation in their care, and efforts can be made to ensure that EMRs are accessible to all, particularly marginalized, groups [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Balancing transparency with privacy is essential in maintaining a supportive patient‒clinician relationship and personalizing the healthcare experience. Equity has received less attention, confirming Dow's view of equity as the \"forgotten aim\" of the STEEEP framework and suggesting a gap for further research, as noted by Penman-Aguilar [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The literature also highlights challenges in achieving health equity through EMRs, such as biases in data affecting underserved populations [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] and ethical concerns about patient care and physician‒patient relationships [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur research addresses this gap by identifying salient elements of EMR quality and integrating these insights within the STEEEP framework. While domains such as efficiency and effectiveness confirmed known themes, the low prioritization of patient-centeredness and equity by stakeholders\u0026mdash;despite their centrality in global digital health principles\u0026mdash;represents a novel and critical finding that warrants further exploration.\u003c/p\u003e \u003cp\u003eIn addition to the STEEEP framework, our study emphasizes two critical areas often underexplored in the literature: EMR implementation and quality assessment. Responders reinforce the importance of these aspects, which aligns with the literature on effective implementation practices and ongoing evaluation. Rizer et al. [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] highlighted the significance of leadership, training, support, and system optimization, whereas Donnelly et al. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] stressed the importance of assessing data reliability and the role of EMRs in quality measurement. Both studies highlight the potential of EMRs to reduce data collection burdens, although further research is needed to expand their implementation. By focusing on both the \u003cem\u003e\"how\"\u003c/em\u003e of EMR implementation and the role of continuous \u003cem\u003equality assessment\u003c/em\u003e, these findings offer a more holistic approach to improving EMR systems. This not only enhances the functionality of the systems but also ensures that they effectively support healthcare professionals in providing high-quality, patient-centered care. Ultimately, insights from EMR assessment grounded in the STEEEP framework and the use of standardized measurement tools and procedures have the potential to drive more efficient, accurate, and accessible healthcare, leading to better health outcomes.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThe study has multiple strengths, including a diverse sample of stakeholders from 14 countries, enriching the findings with various perspectives, experiences, and contextual factors. Additionally, the study benefits from a substantial sample size of 3 pilot interviews and 27 main KIIs, ensuring thematic saturation. The involvement of participants from various stakeholder groups enhances the research's relevance and applicability, while the study's findings hold potential for guiding future investigations. The participants were initially invited through the study team's global network, supplemented by snowball sampling, to expand the participant pool. Despite the unequal distribution of participants across categories, with EMR builders and implementers numbering 16, domain experts 5, and decision makers 6, our study included enough participants from each group.\u003c/p\u003e \u003cp\u003eA limitation of the study is that the majority of our participants were from African countries, which could limit the transferability of our findings to other regions of the world. This concentration can be explained by the fact that the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has invested strongly in scaling EMRs for HIV treatment programs in LMICs, especially in the African region. This means that the findings may not be fully representative of the entire population and may not provide a complete understanding of the research question.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eOur study reveals the perspectives of stakeholders regarding EMR quality, highlighting the significance of clinical decision support, data quality, and stakeholder engagement. Effectiveness and efficiency were identified as the most frequently discussed domains. Notably, patient-centeredness and equity received less focus, indicating domains that require further research.\u003c/p\u003e\n\u003cp\u003eImplications for Healthcare Quality:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cem\u003eEffectiveness and efficiency:\u003c/em\u003e EMRs should prioritize decision support and data quality while addressing cost and training needs. Enhancing interoperability should be a key goal, facilitating seamless data exchange to improve healthcare delivery.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003ePatient-centeredness:\u003c/em\u003e The gap in this area calls for a focus on design principles that cater to patient needs and preferences.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eEquity:\u003c/em\u003e The observed lack of focus on equity suggests a need for targeted research to promote equitable access and outcomes.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThese insights offer a roadmap for healthcare organizations and policymakers to improve EMR quality and implementation effectively.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEMR \u0026ndash; Electronic Medical Record\u003c/p\u003e\n\u003cp\u003eHIS \u0026ndash; Health Information System\u003c/p\u003e\n\u003cp\u003eLMIC \u0026ndash; Low- and Middle-Income Country\u003c/p\u003e\n\u003cp\u003eKIIs \u0026ndash; Key Informant Interviews\u003c/p\u003e\n\u003cp\u003eSTEEEP \u0026ndash; Safety, Timeliness, Effectiveness, Efficiency, Equity, and Patient-centeredness\u003c/p\u003e\n\u003cp\u003ePDD \u0026ndash; Principles for Digital Development\u003c/p\u003e\n\u003cp\u003ePEPFAR \u0026ndash; President\u0026apos;s Emergency Plan for AIDS Relief\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate.\u003cbr\u003e\u0026nbsp;This study was reviewed and approved by the University of Washington's Human Subjects Division (Study00016157) and was categorized as exempt. All research procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Verbal informed consent was obtained from all individual participants prior to their inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003cbr\u003e\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003cbr\u003e\u003c/strong\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to privacy restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003cbr\u003e\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003cbr\u003e\u003c/strong\u003eThis study was conducted as part of a student master’s thesis at the University of Washington and did not receive external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003cbr\u003e\u003c/strong\u003eAS designed the study, conducted interviews, performed data analysis, and led manuscript writing. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003eWe would like to express our sincere gratitude to all the participants who participated in this study. We also acknowledge the invaluable contributions of the DIGI team members. Additionally, we extend our appreciation to the Department of Global Health, the Department of Human-Centered Design and Engineering, the School of Public Health, and the Biobehavioral Nursing and Health Informatics Department at the University of Washington for their support throughout this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEvans RS. Electronic Health Records: Then, Now, and in the Future. Yearbook of Medical Informatics [Internet]. 2016;25(S 01):S48\u0026ndash;61. 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Int J Environ Res Public Health. 2022;20(1):200.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"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":"EMR quality, STEEEP framework, stakeholder perspective, global health, digital health","lastPublishedDoi":"10.21203/rs.3.rs-6827804/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6827804/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMany Low-and middle-income countries (LMICs) are moving rapidly to digitize the health sector, and health leaders need ways to evaluate the quality of available Electronic medical records (EMRs), to guide their investments. Yet EMR quality is an ill-defined concept and methods to operationalize assessment of EMR quality are also lacking. The study investigates domains that stakeholders in LMICs consider crucial to quality of EMRs using the STEEEP framework\u0026mdash;Safety, Timeliness, Effectiveness, Efficiency, Equity, and Patient-centeredness.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMaterials and methods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe conducted 27 individual semi structured virtual interviews across 14 countries with diverse stakeholders, including EMR builders, implementers, domain experts, and decision-makers, to explore the factors affecting EMR quality globally. We used deductive and inductive approaches to identify salient themes within the six STEEEP domains.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSalient factors included technical, environmental, and human issues, with most stakeholders prioritizing effectiveness and efficiency. Effectiveness encompasses clinical decision support and data quality, whereas efficiency is related to cost, infrastructure, and training. Interoperability was identified as critical to safety and timeliness, whereas patient-centeredness and equity received limited attention.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDiscussion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eStakeholder perceptions reveal the need for a multifaceted approach to ensure EMR quality, addressing gaps in patient-centeredness and equity\u0026mdash;key principles of digital development. There is a need to sensitize stakeholders in these domains and integrate assessments into EMR evaluations, particularly in LMICs, to improve healthcare equity.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOur study highlights stakeholder perspectives on defining a practical framework for assessing EMR quality in LMICs, but further work is needed to operationalize the domains of patient-centeredness and equity.\u003c/p\u003e","manuscriptTitle":"Domains of Electronic Medical Records Quality in Global Health: Stakeholder Perspectives Using the STEEEP Framework","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-18 09:14:59","doi":"10.21203/rs.3.rs-6827804/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-07T09:15:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-04T20:35:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"88603792889700736979884501645500954513","date":"2025-12-23T14:14:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103424893636309950397620713088932341479","date":"2025-12-17T06:20:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-02T10:18:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"145073579985774731133497292801326609995","date":"2025-06-22T07:46:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-15T19:59:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-14T13:22:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-13T11:37:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-12T11:20:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-06-12T11:16:59+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":"81053161-75bc-44c1-9c2d-00c0adb01722","owner":[],"postedDate":"June 18th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-07T09:15:38+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-12T11:24:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-18 09:14:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6827804","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6827804","identity":"rs-6827804","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}