KEY WORDS operational research; SORT IT; non-communicable disease; electronic medical record system; Malawi Managing and monitoring chronic non-communicable diseases in a primary health care clinic, Lilongwe, Malawi R. C. Manjomo, 1 B. Mwagomba, 2 S. Ade, 3,4 E. Ali, 5 A. Ben-Smith, 6 P. Khomani, 1 P. Bondwe, 1 D. Nkhoma, 1 G. P. Douglas, 7 K. Tayler-Smith, 5 L. Chikosi, 8 A. D. Harries,3,9 O. J. Gadabu 1 C hronic non-communicable diseases (NCDs) are now the world's leading cause of mortality, with a significant and rapidly growing impact in low-and middle-income countries (LMICs). 1,2 In 2010, there were 34.5 million deaths (two of every three deaths globally) due to NCDs, with cancer, ischaemic heart disease, stroke and diabetes being the predominant causes. 3 Despite the increasing burden of disease and associated mortality, access to prevention, care and treatment remains out of reach for most people in LMICs, and as a result there have been calls for action to improve the situation. 4,5 In September 2011, the United Nations convened a high-level meeting on NCDs, and agreement was reached on a goal to reduce NCD deaths by 25% by 2025 in people aged 30-70 years. 6,7 This was taken forward into the Sustainable Development Goals (SDG), with SDG 3.4 aiming to reduce premature mortality from NCDs by one third by 2030. 8 The targets selected to achieve this goal include reducing elevated blood pressure, smoking cessation, reducing salt intake and increasing physical activity. While there is increasing agreement about the upstream policies required to combat NCDs and reduce NCD mortality, far less is known downstream about how to deliver and monitor quality services for the prevention, care and treatment of chronic disease for the millions of people in need.In LMICs, patients with NCDs are usually managed in tertiary or secondary level hospitals, but there is an urgent and important need to know how to decentralise and integrate the management of NCDs into primary health care and how to monitor the incidence and prevalence of disease, treatment outcomes and associated morbidity and mortality in this setting. A recent study from Kenya reported on the integrated management of patients with hypertension and/or diabetes in a primary health care setting supported by Médecins Sans Frontières (MSF), with encouraging results. 9 There is little information, however, about how this could work at the peripheral level in government settings in other LMICs.In Malawi, a nationwide World Health Organization (WHO) STEPwise approach to Surveillance (STEPS) survey showed that in 2009 respectively 33% and 6% of the population surveyed had hypertension and diabetes mellitus (DM); 10 as a result, a Non-Communicable Diseases Management Unit was established within the Ministry of Health. A national strategy and action plan for NCDs has been developed, including the roll-out of the concept of a 'chronic care clinic'. Currently, most patients with NCDs such as hypertension, DM, asthma and epilepsy are managed in one of the four national te...
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 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.
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