Usability of UgandaEMR+ among health workers in Uganda: adaptation and evaluation of the System Usability Scale in a low- resource EMR environment

Abstract Background Electronic medical record (EMR) systems are being rapidly scaled across sub-Saharan Africa, yet evidence on their usability from the perspective of frontline health workers remains limited, particularly for open-source platforms deployed in low-resource settings. UgandaEMR + is a OpenMRS 3-based national EMR in Uganda which has been deployed in over 1,000 facilities, yet no study has assessed its usability using a validated instrument. This study adapted and applied the System Usability Scale (SUS) to evaluate UgandaEMR+ usability across four Ugandan health facilities and to identify item-level usability patterns that explain low routine adoption. Methods A cross-sectional survey of 302 health workers was conducted at four purposively selected facilities (two regional referral hospitals and two Health Centre IVs) in Uganda. Usability was measured using a 10-item Likert scale (US1–US10) adapted from the SUS and contextualised for UgandaEMR+. Four items were reverse-coded (complexity, inconsistency, cumbersomeness, high learning demand). Internal consistency was assessed using Cronbach’s alpha. Composite scores were categorised as Low (< 3.0), Moderate (3.0–3.9), or High (≥ 4.0). Item-level response distributions were analysed descriptively and triangulated with qualitative findings from 10 semi-structured key-informant interviews to explain the usability patterns observed. Results The overall mean usability score was 3.44 (SD = 0.83), and the adapted scale demonstrated good internal consistency (α = 0.82). When categorised, 28.1% of respondents fell into the low-usability group, 43.7% into moderate, and 28.1% into high. Item-level analysis revealed that the four reverse-coded items, namely Cumbersome (US8, 52.6% agreed), Complexity (US2, 44.4%), Inconsistency (US6, 49.7%), and High Learning Demand (US10, 48.3%), received the highest agreement rates, indicating that usability burden concentrates on operational friction rather than core functionality. Qualitative interviews attributed these patterns to unreliable power, hybrid paper–digital workflows, and inconsistent on-site IT support. Conclusions UgandaEMR+ usability is moderate but marked by specific friction points, including cumbersomeness, complexity, and inconsistency, that suppress routine adoption. Improving power infrastructure, workflow alignment, and responsive IT support would shift usability perceptions more effectively than software redesign alone. The adapted SUS instrument (α = 0.82) is a practical tool for usability monitoring in similar low-resource EMR settings.