National Electronic Health Record Coverage in Pacific Island Countries and Territories: Environmental Scan

Pacific Island countries and territories (PICTs) face unique challenges in delivering health care and sustaining digital health systems. These challenges include geographically dispersed populations and service delivery points, workforce shortages, and poor infrastructure. National electronic health records (EHRs) can strengthen health systems by facilitating continuity of care but are only available in 47% of countries worldwide. The status of national EHRs in PICTs has not been previously described in the published literature.

This study aimed to map national EHR coverage in 14 PICTs of the World Health Organization (WHO) Western Pacific Region classified as Small Island Developing States (SIDS). This included the presence or absence of a national EHR; identification of EHR software used; coverage nationally and across primary, secondary, and tertiary facilities; presence or absence of supporting digital health or health information system strategies and policies; comparison of national EHR coverage in PICTs with national EHR coverage globally; and exploration of a relationship between EHR coverage and country income in PICTs.

Given the absence of peer-reviewed literature on EHRs in PICTs, an environmental scan methodology was selected to review gray literature sources. We conducted a 3-stage environmental scan to systematically search publicly available websites across government, bilateral, multilateral, and philanthropic organizations for documents describing the status of national EHR implementations in the aforementioned 14 PICTs.

Of the 14 PICTs assessed, 12 countries (86%) have an EHR implemented at some level of the public health system, and 8 (57%) have a single national system implemented at more than one facility. Although this is higher than national EHR coverage rates globally (57/122, 47%), average coverage across the 12 PICTs using EHRs was only 39% (median 16%). We also identified a positive relationship between EHR coverage and country income status and generally medium to high EHR coverage across tertiary hospitals (19/41, 46%) and secondary care facilities (29/77, 38%) but low implementation at primary care facilities (61/4158, 1.5%). EHR coverage across all facilities in the 14 countries assessed was 2.5% (108/4267). EHR software used includes Tamanu (Nauru, Palau, Samoa, Kiribati, Fiji [Aspen Medical public-private partnership hospitals]), Medtech (Cook Islands, Niue), Vesalius (Tonga), PATIS Plus (Fiji), and custom systems.

Our findings demonstrate, for the first time, that EHRs are being implemented in PICTs, including at scale in some settings. Despite high apparent coverage in some PICTs, the success of implementation and health worker usage remains unclear. Gray literature indicates that some EHRs currently available are failing or incapable of scaling nationally. To support sustainability of national EHRs in PICTs, governments should prioritize the implementation of fit-for-purpose, open-source, and scalable EHRs, and future studies should assess the success of EHR adoption and impact in the region.