The effect of electronic medical record-based clinical decision support on HIV care in resource-constrained settings: A systematic review

Abstract

Background

It is estimated that one million people infected with HIV initiate anti-retroviral therapy (ART) in resource-constrained countries annually. This occurs against a background of overburdened health workers with limited skills to handle rapidly changing treatment standards and guidelines hence compromising quality of care. Electronic medical record (EMR)-based clinical decision support systems (CDSS) are considered a solution to improve quality of care. Little evidence, however, exists on the effectiveness of EMR-based CDSS on quality of HIV care and treatment in resource-constrained settings.

Objective

The aim of this systematic review was to identify original studies on EMR-based CDSS describing process and outcome measures as well as reported barriers to their implementation in resource-constrained settings. We characterized the studies by guideline adherence, data and process, and barriers to CDSS implementation.

Methods

Two reviewers independently assessed original articles from a search of the MEDLINE, EMBASE, CINAHL and Global Health Library databases until January 2012. The included articles were those that evaluated or described the implementation of EMR-based CDSS that were used in HIV care in low-income countries.

Results

A total of 12 studies met the inclusion criteria, 10 of which were conducted in sub-Saharan Africa and 2 in the Caribbean. None of the papers described a strong (randomized controlled) evaluation design. Guideline adherence: One study showed that ordering rates for CD4 tests were significantly higher when reminders were used. Data and process: Studies reported reduction in data errors, reduction in missed appointments, reduction in missed CD4 results and reduction in patient waiting time. Two studies showed a significant increase in time spent by clinicians on direct patient care. Barriers to CDSS implementation: Technical infrastructure problems such as unreliable electric power and erratic Internet connectivity, clinicians’ limited computer skills and failure by providers to comply with the reminders are key impediments to the implementation and effective use of CDSS.

Conclusion

The limited number of evaluation studies, the basic and heterogeneous study designs, and varied outcome measures make it difficult to meaningfully conclude on the effectiveness of CDSS on quality of HIV care and treatment in resource-limited settings. High quality evaluation studies are needed. Factors specific to implementation of EMR-based CDSS in resource-limited setting should be addressed before such countries can demonstrate its full benefits. More work needs to be done to overcome the barriers to EMR and CDSS implementation in developing countries such as technical infrastructure and care providers’ computer illiteracy. However, simultaneously evaluating and describing CDSS implementation strategies that work can further guide wise investments in their wider rollout.

Introduction

The 2010 Progress Report “Towards Universal Access” for HIV services reported that 5.25 million people infected with HIV in low-middle income countries were receiving life-saving antiretroviral therapy (ART) at the end of 2009, representing an increase of 1.2 million people since December 2008 [1]. The greatest proportion of these patients (74%) were in sub-Saharan Africa. HIV/AIDS is a chronic disease and treatment guidelines require that patients on ART visit health care providers monthly, resulting in ongoing collection of longitudinal data to monitor treatment [2], [3], [4]. Case finding, enrolling in pre-ART care, tracking CD4 levels regularly, starting ART treatment, ensuring adherence and monitoring side effects are essential components of HIV care. The rapid annual increase in number of patients in a setting of overworked clinical staff with limited training potentially compromises quality of care and requires solutions that enable optimal care provision. Electronic medical record (EMR) systems are considered to be such a solution, especially when they support the implementation of guidelines through Clinical Decision Support Systems (CDSS) [5], [6].

The use of EMR-based CDSS has been shown to improve quality of health care. This has been demonstrated through better diagnosis, reduced medication errors [5], [7] and improved practitioner performance [8]. Studies conducted in the US and other developed countries have shown that CDSS can improve quality of HIV care through improved compliance with guidelines [9], [10]. On the other hand, a systematic review by Tawadrous et al. showed that many studies were often limited by the evaluation method used and benefits can only be reported selectively [11].

The increasing number of patients enrolling on HIV treatment has led to an increase in the number of EMRs developed to document, monitor and manage patient care in developing countries [6]. As with other health care innovations, EMRs and CDSS must be rigorously evaluated to establish their benefits before scaling up their use in clinical practice. Many systematic reviews on CDSS that have been conducted and published such as [8], [11], [12], describe experiences from developed countries. None has so far focused on resource-constrained settings where unique challenges and barriers to implementation of EMRs are encountered. To justify further investment of resources from a highly competitive funding environment for the development and implementation of EMRs with CDSS in resource-poor countries, evidence on their benefits, barriers and overall impact on health outcomes is needed.

We conducted a systematic literature review to identify published original studies on EMR-based CDSS describing process and outcome measures as well as reported barriers to their implementation in resource-constrained settings. We characterized the studies by adherence to clinical guidelines, data and process, and implementation barriers.