Current practices, challenges and enabling factors for electronic medical record implementation in Uganda: a convergent mixed- methods study

<title>Abstract</title> <p> Background Electronic medical records (EMRs) are critical for strengthening health service delivery in low- and middle-income countries, yet real-world adoption remains uneven. In Uganda, UgandaEMR+ covers only approximately 16.7% of health facilities, and even within deploying facilities, routine use is inconsistent. This study investigated current EMR practices, implementation challenges and enabling factors across four Ugandan health facilities to inform evidence-based strategies for sustainable scale-up. Methods A convergent mixed-methods design was used at four purposively selected facilities: Lira Regional Referral Hospital, Hoima Regional Referral Hospital, Kyangwali Health Centre IV, and Kawaala Health Centre IV. The quantitative strand surveyed 302 health workers using a structured questionnaire covering EMR use frequency, a 10-item perceived Challenges scale (CH1–CH10), and a 10-item perceived Facilitators scale (FA1–FA10). The qualitative strand comprised 10 semi-structured key-informant interviews and structured workflow observations. Quantitative data were analysed using descriptive statistics, chi-square (χ²) tests, and multivariable binary logistic regression. Internal consistency was assessed using Cronbach’s alpha (α = 0.84–0.86). Qualitative data were analysed thematically with 20% double-coding. Results EMR use differed significantly across facilities (χ², <italic>p</italic>  = 0.005), with high-use proportions ranging from 29.6% at Kawaala HC IV to 60.0% at Kyangwali HC IV. Years of EMR experience was the strongest predictor of use ( <italic>p</italic>  &lt; 0.001), while one-time formal training showed no significant association ( <italic>p</italic>  = 0.465). Perceived challenges were substantial (mean 3.56, SD 0.61); 75.2% of respondents reported moderate or high challenge levels. The most endorsed barriers were staff shortages at peak periods (CH7, 58.3%), time-consuming data entry (CH9, 58.3%), and duplicate documentation (CH5, 57.6%). Facilitating conditions were weak (mean 2.66, SD 0.85); reliable IT support (FA3) and peer-champion support (FA7) were most strongly absent. Qualitative interviews converged with these patterns, attributing them to hybrid paper–digital workflows, weak technical escalation, and inconsistent on-site support. Conclusions EMR implementation is shaped more by facility-level conditions and accumulated user experience than by one-time training. Priority strategies include treating power and connectivity as clinical safety infrastructure, building responsive IT escalation pathways, aligning reporting workflows with EMR outputs, and shifting to continuous, workflow-embedded training. </p>