Towards a theoretical understanding of workarounds emerging from use of a referral mobile application: A developing country context

Health Information Systems (HIS) in public health institutions are currently not used as intended; health care providers (HCPs) are increasingly resorting to workarounds or informal systems known as "Shadow Information Technologies"to accomplish their work. This multiple case study in three public hospitals in South Africa and Namibia describes factors driving the enactment of workarounds to the Vula mobile referral application. An interpretive paradigm was taken and semi-structured interviews conducted with 29 HCPs were analysed using a thematic analysis approach. Substantial evidence is found indicating misfits between work and use of referral applications in public hospitals. A conceptual framework is developed to explain workaround practices based on emerging concepts. The study finds that there is misfit between work and use e-referral applications in public hospitals. As a result, HCPs are enacting workarounds in a form of 1) Shadow IT (Information technology), 2) Augmenting existing systems by using alternative computer-based, telephonic and paper-based referrals 3) Fitting by adapting the e-referral application to accommodate misfits with work activities. These practices suggest a design-reality gap in failing to accommodate these issues in the e-referral application design. Additionally, these practices have brought severe security risks to clinical information used on shadow systems, compromising the privacy and confidentiality of patient information. Public health institutions therefore need to develop more effective measures, policies, and strategies to address unresolved constraints in the referral system.