Assessing EHR potential for adaptive learning in multimorbidity care in Sub-Saharan Africa: a mixed-methods study of Zimbabw’s Impilo system
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Electronic health records (EHR) are increasingly recognised as critical digital infrastructure for integrated, patient-centred care in the context of rising multimorbidity. In low-resource settings, national EHRs may also support locally driven learning to improve adaptive care across chronic conditions. However, there is limited empirical evidence on whether and how these systems enable learning within routine care in ways that inform broader system adaptation. We conducted a qualitative multi-method assessment of Impilo, Zimbabw’s national EHR, to examine its capacity to support learning for integrated multimorbidity care at primary care level, using HIV-hypertension as a tracer condition pair. Guided by Friedman’s socio-technical infrastructure model as the analytical framework and Learning Health Systems (LHS) theory as the interpretive framework, data were drawn from documentary review, ethnographic observation, patient journey mapping, and interviews with frontline health workers and key stakeholders.
Frontline learning for person-centred multimorbidity care was actively generated through interpretation of patient trajectories, experiential adjustment, and coordination across HIV and hypertension services using both the EHR and paper-based artefacts such as registers and patient booklets. However, this learning remained largely encounter-bound and weakly stabilised. Impilo did not routinely provide usable longitudinal patient views, practice-facing analytic tools, or institutionalised mechanisms for collective reflection required to support integrated multimorbidity care. Consequently, learning was largely confined to incremental adjustment within existing workflows, with limited capacity to inform broader changes to care pathways, routines, or system design.
These findings suggest that the principal barrier to developing LHS is not the absence of data or frontline learning capacity, but the lack of socio-technical arrangements that enable learning to stabilise and inform system adaptation. Digitalisation alone is insufficient to support adaptive multimorbidity care. Co-production with frontline health workers may provide a pathway for aligning digital system design with routine care realities.
Author summary
Electronic health records are increasingly used to support integrated care for people living with multiple long-term conditions, including HIV and hypertension. However, they practically remain organised around single diseases and reporting requirements, limiting their ability to support coordinated, person-centred care. We studied Zimbabw’s national electronic health record system, Impilo, to understand how it supports integrated HIV and hypertension care in primary healthcare settings. We found that frontline health workers routinely generated practical knowledge by interpreting patient histories, coordinating care across services, and combining paper and electronic records to maintain continuity of care. However, much of this learning remained informal and tied to individual patient encounters because the system did not routinely provide longitudinal patient views, coordinated follow-up, or integrated information across conditions. Our findings suggest that the main challenge is not a lack of data, digital systems, or frontline expertise, but the limited ability of current systems to support learning and adaptation for multimorbidity care. Involving frontline health workers in the design and improvement of electronic health records may help create more integrated, learning-oriented health systems.
