SMARTHealth India: Development and Field Evaluation of a Mobile Clinical Decision Support System for Cardiovascular Diseases in Rural India.
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2014-12-09
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Abstract
BACKGROUND Cardiovascular disease CVD is the major cause of premature death and disability in India and yet few people at risk of CVD are able to access best practice health care Mobile health mHealth is a promising solution but very few mHealth interventions have been subjected to robust evaluation in India OBJECTIVE The objectives were to develop a multifaceted mobile clinical decision support system CDSS for CVD management and evaluate it for use by public nonphysician health care workers NPHWs and physicians in a rural Indian setting METHODS Plain language clinical rules were developed based on standard guidelines and programmed into a computer tablet app The algorithm was validated and field tested in 11 villages in Andhra Pradesh involving 11 NPHWs and 3 primary health center PHC physicians A mixed method evaluation was conducted comprising clinical and survey data and in depth patient and staff interviews to understand barriers and enablers to the use of the system Then this was thematically analyzed using NVivo 10 RESULTS During validation of the algorithm there was an initial agreement for 70 of the 42 calculated variables between the CDSS and SPSS software outputs Discrepancies were identified and amendments were made until perfect agreement was achieved During field testing NPHWs and PHC physicians used the CDSS to screen 227 and 65 adults respectively The NPHWs identified 39 88 227 of patients for referral with 78 69 88 of these having a definite indication for blood pressure BP lowering medication However only 35 24 69 attended a clinic within 1 month of referral with 42 10 24 of these reporting continuing medications at 3 month follow up Physicians identified and recommended 17 11 65 of patients for BP lowering medications Qualitative interviews identified 3 interrelated interview themes 1 the CDSS had potential to change prevailing health care models 2 task shifting to NPHWs was the central driver of change and 3 despite high acceptability by end users actual transformation was substantially limited by system level barriers such as patient access to doctors and medicines CONCLUSIONS A tablet based CDSS implemented within primary health care systems has the potential to help improve CVD outcomes in India However system level barriers to accessing medical care limit its full impact These barriers need to be actively addressed for clinical innovations to be successful TRIAL REGISTRATION Clinical Trials Registry of India CTRI 2013 06 003753 http ctri nic in Clinicaltrials showallp php mid1 6259AndEncHid 51761 70513AnduserName CTRI 2013 06 003753 Archived by WebCite at http www webcitation org 6UBDlrEuq