Implementing an electronic health record system in a tertiary care surgical oncology setup – A mixed method analysis

Background: Electronic Health Record (EHR) implementation in low- and middle-income countries (LMICs) remains constrained by infrastructure limitations, dual documentation requirements, and limited local evidence on workflow impact-particularly in time-sensitive oncology settings. We evaluated the implementation of a modular, cloud-based EHR system in a tertiary surgical oncology unit in Sri Lanka operating in parallel with mandatory paper documentation. Methods: A convergent mixed-methods study was conducted during the first six months of implementation. Quantitatively, paired comparisons were performed for 100 consecutive theatre lists and 100 consecutive biopsy-confirmed malignancy cases to assess changes in theatre-list preparation time and biopsy-to-diagnosis interval. Mean differences with 95% confidence intervals (CIs) and effect sizes (Cohen's dz) were calculated. Concurrently, 26 healthcare professionals completed an investigator-designed usability survey; descriptive statistics were reported, and exploratory inferential analyses were performed. Open-text responses underwent reflexive thematic analysis. Results: The EHR significantly reduced theatre-list preparation time from 4.10 minutes to 2.40 minutes (mean reduction 1.70 minutes; 95% (CI 1.44-1.96); Cohen's dz = 1.29; p < 0.0001). The biopsy-to-diagnosis interval decreased from 14.95 days to 8.40 days (mean reduction 6.55 days; 95% (CI 4.52-8.58; Cohen's dz = 0.64; p < 0.0001). Overall user satisfaction was high (mean 4.31/5, SD 0.55). Training adequacy was associated with higher satisfaction (mean difference 0.47; p = 0.035), and satisfaction correlated with ease of data entry (r = 0.60, p = 0.001). Qualitative analysis identified four themes: improved information retrieval, enhanced multidisciplinary coordination, hybrid documentation burden, and infrastructure-related optimisation needs. Survey inferential findings are exploratory due to use of a non-validated instrument. Conclusions: In a resource-constrained oncology setting, implementation of a secure, cloud-based EHR was associated with substantial workflow efficiency gains and strong user acceptability, despite operating within a hybrid paper-electronic environment. Findings support the feasibility and measurable impact of context-sensitive digital transformation in LMIC tertiary services, while underscoring the importance of infrastructure reliability, structured training, and deliberate transition away from dual documentation for sustainable scale-up.