Impact of an electronic clinical decision support system on workflow in antenatal care: the QUALMAT eCDSS in rural health care facilities in Ghana and Tanzania

Abstract

BackgroundThe implementation of new technology can interrupt established workflows in health care settings. The Quality of Maternal Care (QUALMAT) project has introduced an electronic clinical decision support system (eCDSS) for antenatal care (ANC) and delivery in rural primary health care facilities in Africa.ObjectiveThis study was carried out to investigate the influence of the QUALMAT eCDSS on the workflow of health care workers in rural primary health care facilities in Ghana and Tanzania.DesignA direct observation, time-and-motion study on ANC processes was conducted using a structured data sheet with predefined major task categories. The duration and sequence of tasks performed during ANC visits were observed, and changes after the implementation of the eCDSS were analyzed.ResultsIn 24 QUALMAT study sites, 214 observations of ANC visits (144 in Ghana, 70 in Tanzania) were carried out at baseline and 148 observations (104 in Ghana, 44 in Tanzania) after the software was implemented in 12 of those sites. The median time spent combined for all centers in both countries to provide ANC at baseline was 6.5 min [interquartile range (IQR) =4.0–10.6]. Although the time spent on ANC increased in Tanzania and Ghana after the eCDSS implementation as compared to baseline, overall there was no significant increase in time used for ANC activities (0.51 min, p=0.06 in Ghana; and 0.54 min, p=0.26 in Tanzania) as compared to the control sites without the eCDSS. The percentage of medical history taking in women who had subsequent examinations increased after eCDSS implementation from 58.2% (39/67) to 95.3% (61/64) p<0.001 in Ghana but not in Tanzania [from 65.4% (17/26) to 71.4% (15/21) p=0.70].ConclusionsThe QUALMAT eCDSS does not increase the time needed for ANC but partly streamlined workflow at sites in Ghana, showing the potential of such a system to influence quality of care positively.

Opportunities and obstacles using a clinical decision support system for maternal care in Burkina Faso

“…Furthermore; the HCWs considered that they get guidance for routine questions through using the CDSS where they usually needed colleagues' advice. This is in concordance with the users from Ghana and Tanzania, who also reported that they have learnt by using the CDSS (13,21). In Ghana (13), the HCWs were not asking for information about patients' history before they started to use the CDSS, but started to do so after implementation of the CDSS according to WHO and National health authorities (13).…”

“…This creates unwillingness to use the CDSS due to extra efforts this may need. Indeed using the same CDSS, HCWs in Ghana and Tanzania reported that the use of the CDSS multiplied the time spent for ANC by 2.6 in Ghana (going from 7.4 minutes to 19.2 minutes) and 1.7 in Tanzania (going from 15.1 minutes to 25.5 minutes) (13). This is in line with our findings in Burkina Faso where the HCWs reported the time spent for ANC is 15 minutes more with the CDSS.…”

“…The CDSS intervention was carried out in Burkina Faso, in Ghana and in Tanzania (3,13,14,21) with two main sections (13): a checklist ensuring that all relevant data are carried out and algorithms that screening the entered data for pathological issue and give immediate alerts or comprehensive recommendations.…”

“…Designing a CDSS without considering the user perspective fails to provide interest, and can raise resistance to their use in daily practice (7,(9)(10)(11). The benefits of CDSS systems are ensured if they have a specific purpose, are "easy to use" and are adapted to the workflow at the healthcare facility (3,6,7,12,13).…”

Quality of antenatal and childbirth care in rural health facilities in Burkina Faso, Ghana and Tanzania: an intervention study

“…Details on the aim, development, implementation and costs of the eCDSS are described elsewhere [14,[31][32][33][34][35]. In brief, after a piloting period (including initiation of the eCDSS implementation, testing, translation), the official use of the eCDSS started at the research PHC facilities in November 2012 and was implemented for about 14 months before conducting the post-intervention quality assessment [14,34].…”