Gerald P. Douglas

Using touchscreen electronic medical record systems to support and monitor national scale-up of antiretroviral therapy in Malawi.

Gerry Douglas and colleagues describe the rationale and their experience with scaling up electronic health records in six antiretroviral treatment sites in Malawi.

Applying lessons learnt from the 'DOTS' Tuberculosis Model to monitoring and evaluating persons with diabetes mellitus in Blantyre, Malawi

The global burden of diabetes mellitus (DM) is immense and predicted to reach 438 million by 2030, with 80% of the cases being in the developing world. The management of chronic non‐communicable diseases like DM is poor in most resource‐limited settings, and the ‘directly observed therapy, short course’ (DOTS) framework for tuberculosis control has been proposed as a feasible way to improve this situation. In late 2009, aspects of the DOTS model were applied to the management of persons with DM in the diabetes clinic in Queen Elizabeth Central Hospital, Blantyre, Malawi, and a point‐of‐care electronic medical record system was set up to support and monitor patients in care. This is the first quarterly and cumulative report of persons with DM registered for care stratified by treatment outcomes, complications and medication history up to 31 December 2010. There were 170 new patients registered between October and December 2010, with 1864 ever registered by 31 December 2010. Most patients were alive and in care; 3 died, 53 defaulted and 3 transferred out. Of those on oral hypoglycaemic agents, metformin was most commonly used. Complications were common. The monitoring and evaluation will be further refined, and at the same time, the systems developed in Blantyre will be expanded to other parts of the country.

Computer-supported feedback message tailoring: theory-informed adaptation of clinical audit and feedback for learning and behavior change.

BackgroundEvidence shows that clinical audit and feedback can significantly improve compliance with desired practice, but it is unclear when and how it is effective. Audit and feedback is likely to be more effective when feedback messages can influence barriers to behavior change, but barriers to change differ across individual health-care providers, stemming from differences in providers’ individual characteristics.DiscussionThe purpose of this article is to invite debate and direct research attention towards a novel audit and feedback component that could enable interventions to adapt to barriers to behavior change for individual health-care providers: computer-supported tailoring of feedback messages. We argue that, by leveraging available clinical data, theory-informed knowledge about behavior change, and the knowledge of clinical supervisors or peers who deliver feedback messages, a software application that supports feedback message tailoring could improve feedback message relevance for barriers to behavior change, thereby increasing the effectiveness of audit and feedback interventions. We describe a prototype system that supports the provision of tailored feedback messages by generating a menu of graphical and textual messages with associated descriptions of targeted barriers to behavior change. Supervisors could use the menu to select messages based on their awareness of each feedback recipient’s specific barriers to behavior change. We anticipate that such a system, if designed appropriately, could guide supervisors towards giving more effective feedback for health-care providers.SummaryA foundation of evidence and knowledge in related health research domains supports the development of feedback message tailoring systems for clinical audit and feedback. Creating and evaluating computer-supported feedback tailoring tools is a promising approach to improving the effectiveness of clinical audit and feedback.

Modeling return on investment for an electronic medical record system in Lilongwe, Malawi

Objective To model the financial effects of implementing a hospital-wide electronic medical record (EMR) system in a tertiary facility in Malawi. Materials and Methods We evaluated three areas of impact: length of stay, transcription time, and laboratory use. We collected data on expenditures in these categories under the paper-based (pre-EMR) system, and then estimated reductions in each category based on findings from EMR systems in the USA and backed by ambulatory data from low-income settings. We compared these potential savings accrued over a period of 5 years with the costs of implementing the touchscreen point-of-care EMR system at that site. Results Estimated cost savings in length of stay, transcription time, and laboratory use totaled US

Barriers to using eHealth data for clinical performance feedback in Malawi: A case study.

284 395 annually. When compared with the costs of installing and sustaining the EMR system, there is a net financial gain by the third year of operation. Over 5 years the estimated net benefit was US

Managing and Monitoring Chronic Non-Communicable Diseases in a Primary Health Care Clinic, Lilongwe, Malawi

613 681. Discussion Despite considering only three categories of savings, this analysis demonstrates the potential financial benefits of EMR systems in low-income settings. The results are robust to higher discount rates, and a net benefit is realized even under more conservative assumptions. Conclusions This model demonstrates that financial benefits could be realized with an EMR system in a low-income setting. Further studies will examine these and other categories in greater detail, study the financial effects at different levels of organization, and benefit from post-implementation data. This model will be further improved by substituting its assumptions for evidence as we conduct more detailed studies.

Touchscreen task efficiency and learnability in an electronic medical record at the point-of-care.

INTRODUCTION Sub-optimal performance of healthcare providers in low-income countries is a critical and persistent global problem. The use of electronic health information technology (eHealth) in these settings is creating large-scale opportunities to automate performance measurement and provision of feedback to individual healthcare providers, to support clinical learning and behavior change. An electronic medical record system (EMR) deployed in 66 antiretroviral therapy clinics in Malawi collects data that supervisors use to provide quarterly, clinic-level performance feedback. Understanding barriers to provision of eHealth-based performance feedback for individual healthcare providers in this setting could present a relatively low-cost opportunity to significantly improve the quality of care. OBJECTIVE The aims of this study were to identify and describe barriers to using EMR data for individualized audit and feedback for healthcare providers in Malawi and to consider how to design technology to overcome these barriers. METHODS We conducted a qualitative study using interviews, observations, and informant feedback in eight public hospitals in Malawi where an EMR system is used. We interviewed 32 healthcare providers and conducted seven hours of observation of system use. RESULTS We identified four key barriers to the use of EMR data for clinical performance feedback: provider rotations, disruptions to care processes, user acceptance of eHealth, and performance indicator lifespan. Each of these factors varied across sites and affected the quality of EMR data that could be used for the purpose of generating performance feedback for individual healthcare providers. CONCLUSION Using routinely collected eHealth data to generate individualized performance feedback shows potential at large-scale for improving clinical performance in low-resource settings. However, technology used for this purpose must accommodate ongoing changes in barriers to eHealth data use. Understanding the clinical setting as a complex adaptive system (CAS) may enable designers of technology to effectively model change processes to mitigate these barriers.

Simplicity and usability: lessons from a touchscreen electronic medical record system in Malawi

SETTING Patients with chronic non-communicable diseases attending a primary health care centre, Lilongwe, Malawi. OBJECTIVE Using an electronic medical record monitoring system, to describe the quarterly and cumulative disease burden, management and outcomes of patients registered between March 2014 and June 2015. DESIGN A cross-sectional study. RESULTS Of 1135 patients, with new registrations increasing each quarter, 66% were female, 21% were aged ⩾65 years, 20% were obese, 53% had hypertension alone, 18% had diabetes alone, 12% had asthma, 10% had epilepsy and 7% had both hypertension and diabetes. In every quarter, about 30% of patients did not attend the clinic and 19% were registered as lost to follow-up (not seen for ⩾1 year) in the last quarter. Of those attending, over 90% were prescribed medication, and 80-90% with hypertension and/or diabetes had blood pressure/blood glucose measured. Over 85% of those with epilepsy had no seizures and 60-75% with asthma had no severe attacks. Control of blood pressure (41-51%) and diabetes (15-38%) was poor. CONCLUSION It is feasible to manage patients with non-communicable diseases in a primary health care setting in Malawi, although more attention is needed to improve clinic attendance and the control of hypertension and diabetes.

Monitoring treatment outcomes in patients with chronic disease: lessons from tuberculosis and HIV/AIDS care and treatment programmes

The objective of this study was to determine the relative efficiency of novices compared to a prediction of skilled use when performing tasks using the touchscreen interface of an EMR developed in Malawi. We observed novice users performing touchscreen tasks and recorded timestamp data from their performances. Using a predictive human performance modeling tool, the authors predicted the skilled task performance time for each task. Efficiency and rates of error were evaluated with respect to user interface design. Nineteen participants performed 31 EMR tasks seven times for a total of 4,123 observed performances. We analyzed twelve representative tasks leaving 1,596 performances featuring six user interface designs. Mean novice performance time was significantly slower than mean predicted skilled performance time (p<0.001). However, novices performed faster than the predicted skilled level in 208 (13%) of successful task performances. These findings suggest the user interface design supports a primary design goal of the EMR--to allow novice users to perform tasks efficiently and effectively.

Cohort analysis of antenatal care and delivery outcomes in pregnancy: a basis for improving maternal health.

on overworked ward clerks with little training in medical documentation, overworked clinicians, and documentation policies that are often poorly explained, poorly understood, or irrelevant to clinical practices. In 2000, Gerald Douglas founded Baobab Health, a non-governmental organization devoted to the development of effective EMRs for Malawian healthcare. The Baobab anti-retroviral therapy (BART) system is Baobab’s largest current deployment, with systems currently deployed at 15 high-burden sites managing clinical data for more than 120,000 patients, representing several million clinical encounters. A companion system for diabetes care has been deployed [5], and efforts in progress include expanding the Baobab model to focus on maternal and child care. Together with companion efforts aimed at providing standardized barcode patient IDs in support of improving continuity of care, Baobab systems have registered more than 1.3 million individuals. A dedication to easy-to-use touchscreen interfaces the complexity of many medical environments? Malawi is a landlocked country in Southern Africa with a population of 15 million. The government of Malawi provides healthcare at no charge to patients through a network of four central hospitals, 24 district hospitals, and roughly 400 health centers nationwide. Healthcare delivery in Malawi is hindered by high levels of morbidity and mortality resulting from endemic disease (primarily Malaria and HIV/ AIDS), and a human-resource crisis in the healthcare sector in which the patient-to-doctor ratio is greater than 50,000:1. By contrast, South Africa has a patient-to-doctor ratio of roughly 1,300:1, and the U.S. ratio is approximately 375:1 [4]. While Malawi spends a greater proportion of its budget on healthcare than most developing countries, medical spending is still very low, with most healthcare being delivered in primary-care outpatient clinics. Systemic challenges associated with the lack of resources include poor clinical-data quality due to reliance When it comes to electronic medical records (EMRs), complexity is often perceived as being the enemy of usability [1]. Computer information systems that must support the range of medical specialties, disciplinary perspectives, and administrative and regulatory requirements found in many modern healthcare environments can often become unwieldy and cumbersome, turning an opportunity for improving care into a potential cause of errors and confusion [2,3]. These difficulties may not be inevitable. The successful use of simple, straightforward touchscreen EMRs for managing antiretroviral therapy (ART) and diabetes in Malawi suggests that well-designed interfaces can be used at a national scale by healthcare workers in low-resource environments. The adoption of touchscreen EMRs in Malawi presents intriguing questions: Can these techniques guide development of comparable systems in other low-resource environments and, ideally, offer guidance in handling in te ra c ti o n s N o ve m b e r + D e c e m b e r 2 0 11