BACKGROUND: The shift to electronic health records has improved care but remains limited in low- and middle-income countries (LMICs) due to infrastructure and funding challenges. Operation Smile International (OSI) previously relied on paper records, limiting quality improvement, research, and follow-up. In 2020, OSI launched a hybrid paper-electronic health record (hPHR) system tailored to LMIC needs. METHODS: Through stakeholder interviews and user-centered design, the team identified key system gaps and developed a hPHR. The hPHR uses Optical Mark Recognition and QR-coded patient IDs to enable digital data capture in low-connectivity environments. Forms were tailored to clinical disciplines and aligned with global standards. Piloted across OSI sites, the system was iteratively refined based on user feedback. RESULTS: From 2021 to 2025, OSI deployed its hPHR system in 350 surgical programs across 23 countries. Implemented with local teams, each deployment involved virtual planning, customized forms, and on-site training for staff and volunteers. The hPHR system documented data from 9686 patients and 5239 operations - mostly cleft repairs. In some countries, abbreviated systems were used to fit local workflows. All data were securely uploaded for analysis, with dashboards built in Power BI to support quality improvement, research, and planning aligned with global surgical care indicators. CONCLUSIONS: The Operation Smile hybrid hPHR is a scalable, sustainable solution for surgical documentation in low-resource settings. Despite ongoing challenges, the hPHR offers a practical bridge between paper and electronic systems, advancing health data capacity in LMICs.
Etemad et al. (Tue,) studied this question.