User experience on the newly implemented Electronic Information Management System of the National STD/AIDS Control Programme

Introduction: Information is vital in managing the response to STI and HIV. An electronic Information Management System(EIMS) was introduced to National STD/AIDS Control Programme (NSACP) in early-2019 to streamline information management. A user experience study of EIMS was a timely need. Objective: This study aimed to describe the user experience of the EIMS at the NSACP clinics (Colombo Central clinic, Balapitiya and Kaluthara.) Methods: EIMS-users were invited by emailing a self-administered questionnaire. Standard Online questionnaire on user experience was used covering a wide range of classical usability aspects (efficiency, perspicuity, dependability) and user experience aspects (originality, stimulation). The responses were rated from -3(horribly-bad) to +3(extremely-good). Mean scores were categorized as negative (<-0.8) positive (>+0.8) and neutral (-0.8-0.8). Users perspectives were gathered using openended questions. Results: Out of 47 invitees, thirty-six responded (76%) to the questionnaire. The majority of the participants were postgraduate trainees or medical-officers (19). The majority (55.6%) had used EIMS for one to six months duration. Best performing aspect was Novelty (rating-1.86). The worstperforming was Dependability (0.56). However, all other aspects were rated above positively. Worst performing single item was system speed with a rating of 0.27. EIMS scored above average in both hedonic (1.17) and pragmatic (0.99) qualities. The overall User experience score of the EIMs was positive (1.04) Conclusion: EIMS has been received positively by the staff using it. The majority found it to be efficient and novel. However, the majority also highlighted the connectivity issues and slowness of the system and wished for a more stable system.


Introduction
The National STD/AIDS Control Programme (NSACP) of the Ministry of Health spearheads the national response to HIV/AIDS in Sri Lanka together with all stakeholders and it networks with a cental clinic, 34 full-time STD clinics and 23 branch STD clinics throughout the country.(1) Information on prevalence and trends of STD/HIV are essential in control and prevention activities of the programme and plays a major role in obtaining Ending AIDS in 2025. (2), (3) Until the year 2019, all these data were managed using the paper-based Information management system. However, this system had issues inherent to any paper-based system like lack of uniformity of recorded data, difficulty in tracing old records, requiring large space to store and difficulty in extracting, analyzing and sharing the relevant information. Reports and returns from the clinics lacked uniformity and timeliness. (1) The Electronic Information Management System (EIMS) was implemented in the NSACP to overcome these issues and streamline information management as the first programme in the government health sector to implement such a system. EIMS is composed of multiple modules for different user categories from patient registration to report/return generation. EIMS started rolling out in late 2018 in NSACP along with two peripheral clinics, and It was a novel experience to the implementors, the end-users and the beneficiaries (patients). Further, users' perceptions on the new system were unexplored until this study, which is essential to identify required system modifications and to ensure better implementation and sustainability of the new Information management system.
This study aimed to describe the user experience of the EIMS at the NSACP Clinics (Colombo Central-clinic, Balapitiya and Kalutara),and to identify areas of EIMS that needs improvement.

Method
A descriptive cross-sectional study was carried out at the National STD/AIDS Control Programme premises and two peripheral clinics Kalutara and Balapitiya in August, 2020. Due to the limited number of primary users of the system, all staff persons who have been given access to EIMS (n=47) were invited to participate in the study. The list of health care workers in said institutes with EIMS access was used as the sampling frame.
EIMS-users of NSACP (Clinic doctors, Nurses, PHIs, PHNs, Pharmacists and MLTs and PHLTs) were invited to the study by emailing a webbased self-administered questionnaire along with an informed consent form. The email was followed by a request call.

Study instrument.
A self-administered questionnaire was developed in English and Sinhala. It was composed of 3 sections; Section-A contained questions collecting demographic data, Section-B included a user experience questionnaire (UEQ) to assess the user perceptions on the EIMS, and Section-C included open-ended questions to gather data on specific downsides of the system and major changes requested in the system.
A standard User Experience Questionnaire (UEQ) for electronic systems (UEQ-online.org) was adopted to measure the user experience on the system. It is an online tool which is used by numerous agencies to evaluate computer systems and online platforms. (4) The questionnaire assessed the systems Hedonic quality (quality of being Pleasant or Unpleasant); represented by the aspects stimulation and novelty). It also assessed the systems Pragmatic quality (quality of being practical); represented by the aspects efficiency, perspicuity and dependability.
Each quality of the system in UEQ was measured by a single question with responses in Likert scale ranging from 1-least favourable to 7-most favourable.(4) A standard scoring system was applied giving a score from -3 (horribly bad) to +3 (extremely good) for each corresponding response. A mean scores were calculated for each UEQ item (quality) and higher mean scores than 0.8 were considered as positive score while mean scores less than -0.8 were named as a negative. Mean scores between -0.8 and 0.8 were considered neutral. (4)

Data Analysis
The database was produced from the webbased questionnaire in Excel format. Statistical package for ocial Sciences (SPSS) version 23 was used to analyze the data. The quantitative data were analyzed with regards to measures of central tendency and dispersion. Categorical data were analyzed with regards to proportions. Qualitative data were analyzed in the form of thematic analysis.
In the analysis of responses in UEQ, response for each item was given a score from -3(horrible bad to 3(extremely good). Then the mean score was calculated for each item (quality) of the system and individual mean scores were calculated for each domain (aspect) namely dependability, efficiency, perspicuity, stimulation and novelty. Similarly, overall mean scores were calculated for hedonic and pragmatic qualities as well as the final overall UE score. Mean scores between -0.8 and 0.8 were considered neutral while higher than 0.8 were positive and lower than -0.8 were negative

Results and discussion
Socio-demographic profile Thirty-six (76.6%) out of 47 invitees responded to the online questionnaire. The mean age of the respondents was 37.8 years (SD=7.6). The largest group of respondents were medical officers / PG Trainees and consultants (n=19). The majority 67% were female. Most (n=21) had worked at NSACP for more than 3 years. The socio-demographic profile of the study participants is shown in table 1.

Usage of the system
The period and the type of usage of the system by participants are shown in table 2. The Majority (56%) had used the system for 1 -6 months duration and the majority (54%) used the system for clerking patients  Each item on the questionnaire was given a score in a way that extremely unfavourable marking on EIMS item was given "-3" while extremely favourable marking on an item of the system was given "3". A score of "0" meant that the item has been scored neutrally. The mean scores of each item, overall scores of each domain, and final UEQ scores are shown in table 3 along with their 95% confidence intervals There was no statistically significant difference in each domain scoring (negative, neutral or positive) with regards to participants gender, working experience or the designation.
Main problems identified in the system Summary of the responses given for the qualitative question inquiring problems in the system is shown in table 4. Network-connectivity issues and slowness of the system was a major complaint of staff persons. This was the main complaint of clinic doctors and persons engaging in registration. The nurses in the bleeding-room and injection room found that space is inadequate to keep EIMS instruments. Some did complain of logistic issues like lack of furniture and electricity access points. Some (especially Doctors and MLTs) highlighted that specific sections of the system still need improvements to make it more user friendly. A nurses and an MLT expressed that the training on EIMS is inadequate. Some users highlighted the fact that few modules are still under development (eg-reporting/return generation and lab serology module) which gives a sense of incompleteness in the system.
In the qualitative responses, a PHI mentioned that " This is the best system I have come across to register patients, We do our work with great ease now" while a nurse responded, " This reduces the report generation time drastically which will be a great help". A doctor mentioned that "It is difficult to build a good rapport as it is difficult to maintain eye contact with the patient." While another stated " system Blunts the thinking and analysing capacity in the view of learning from patients especially for postgraduate trainees" An MLT stated that "Handling Lab equipment's and typing on computing on the same time can result in errors and inconveniences." Requested system changes by the staff members Table 5 summarizes the result of the thematic analysis of the responses received for the question on the user's suggestions to improve the system.
Stable network connectivity was the major request by 19 persons belonging to all the categories followed by request for specific changes in the system and more training opportunities.
The small sample size was a limitation of this study which resulted due to the limited number of staff persons with exposure to the system in the three institutions at the time of data collection.

Conclusions
The EIMS has replaced the old paper-based system almost entirely in the patient registration and the majority of the patient clerking at the centres. The Bleeding room, pharmacy, and the laboratory modules have replaced the old system in the two peripheral clinics. Majority of the staff was using the system.
The user experience questionnaire yielded a positive response from most of the users. None of the user experience scales received a *A single person has given more than one response negative rating. The overall user experience score of the EIMS was above average. It is evident that EIMS has been well received by the majority of the staff members.
The main Issues found in the system was network stability issues, slowness of the system and logistic issues including lack of space. Main suggestions of the users were to have a stable network connection and to have some specific changes to the EIMS so that it is more functional and user-friendly. It is recommended to establish a stable network at the NSACP and while doing some specific changes in the EIMS platform. The system performed well against the user experience questionnaire and expansion of the system to island wide STD clinics is encouraged.