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

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.