Digital health interventions, particularly electronic referrals (e-referrals) and health information systems, have revolutionised clinical workflows in public hospitals by automating processes. However, the utilization of e-referrals has yielded mixed outcomes, with varying levels of success in organisational processes.This paper explores improvisation of health information systems in Southern African public hospitals from a socio-technical perspective. In particular the paper explains the design-reality gaps giving rise to improvisations of mandated health information systems in order to understand their occurrence and impact on referral outcomes. We employed the design-reality framework and the Process framework for Healthcare Information System Workarounds and Impacts to explain the socio-technical issues related to the phenomenon of interest.We conducted semi-interviews with 31 respondents from health organisations as case studies.Respondents from two public hospitals in South Africa and two in Namibia were interviewed to examine how they devised improvisations to various health information systems in each setting.The findings showed that using WhatsApp or improvising existing health information systems (HIS) improved efficiency and productivity of healthcare practitioners (HCPs) referral activities. Additionally, HCPs reported positive outcomes related to continual professional development in the given settings.The findings further show a relationship between design-reality gaps and improvisations enacted by HCPs.The observed gaps are related to poor management systems and structures lack of HCPs' involvement in the roll-out of HIS and inadequacies of existing HIS to support referral tasks.These study findings can be insightful and useful to system developers and other stakeholders for devising measures to address the gaps.

翻译：数字健康干预措施，特别是电子转诊（e-referrals）和健康信息系统，通过流程自动化革新了公立医院的临床工作流。然而，电子转诊的应用效果参差不齐，在组织流程中取得的成功程度不一。本文从社会技术视角探讨了南部非洲公立医院中健康信息系统的即兴应用现象。文章重点阐释了设计-现实差距如何催生对法定健康信息系统的即兴改造，以理解其产生原因及其对转诊结果的影响。我们采用设计-现实框架及医疗信息系统变通与影响的过程框架，来解释与所关注现象相关的社会技术问题。我们以卫生机构的31名受访者为案例进行了半结构化访谈。通过访谈南非两家及纳米比亚两家公立医院的受访者，考察了他们在各自环境中如何针对不同健康信息系统设计即兴应用方案。研究发现，使用WhatsApp或对现有健康信息系统（HIS）进行即兴改造，提高了医疗从业者（HCPs）转诊活动的效率与生产力。此外，医疗从业者报告了在特定环境中持续专业发展方面的积极成果。研究进一步揭示了设计-现实差距与医疗从业者实施的即兴应用之间的关联。观察到的差距涉及管理体系薄弱、医疗从业者缺乏参与健康信息系统部署，以及现有健康信息系统对转诊任务支持不足等问题。这些研究发现可为系统开发者及其他利益相关者制定措施弥合差距提供有价值的参考。