SMARTHealth India: Development and Evaluation of an Electronic Clinical Decision Support System for Cardiovascular Diseases in India

Devarsetty Praveen*, University of Sydney, NSW, Australia
Anushka Patel, The George Institute for Global Health, NSW, Australia
Arvind Raghu, University of Oxford, Oxford, United Kingdom
Gari Clifford, University of Oxford, Oxford, United Kingdom
Pallab Maulik, The George Institute for Global Health, Hyderabad, India
Mohammad Abdul Ameer, The George Institute for Global Health, Hyderabad, India
Lionel Tarrasenko, University of Oxford, Oxford, United Kingdom
David Peiris, The George Institute for Global Health, NSW, Australia

Track: Research
Presentation Topic: Mobile & Tablet Health Applications
Presentation Type: Oral presentation
Submission Type: Single Presentation

Building: Mermaid
Room: Room 4 - Queenshithe
Date: 2013-09-23 04:00 PM – 06:00 PM
Last modified: 2013-09-25

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Background: Cardiovascular diseases (CVD) are a major cause of premature death and disability in both rural and urban India. Wide gaps in the translation of best practice into primary health care exist. M-health interventions for overcoming these gaps hold promise but as yet robust evaluations of such systems is missing.

Objectives: To develop a multifaceted non-physician healthcare worker (NPHWs) intervention utilizing an electronic clinical decision support system (CDSS) and preliminarily evaluate it for utility, effectiveness and acceptability by the community, NPHWs and primary health care (PHC) physicians in this setting.

Methods: A CDSS algorithm for screening and management of CVD was developed based on WHO and country specific guidelines and built as an Android V4.0 application for a 7 inch tablet. The algorithm was validated using a large de-identified existing data-set. First, a physician based validation was conducted followed by comparison of the CDSS output with output from an independent SPSS software programme. The CDSS was then field tested in eleven rural villages of Andhra Pradesh in India. Eleven NPHWs and three PHC physicians were trained to use the tablet to screen, refer and manage consenting adults aged 30+ years over a four week period. Data were uploaded securely to an open source health record. Following field testing, in-depth, semi-structured interviews with all NPHWs and PHC physicians, and a focus group discussion with community participants were conducted and thematically analysed using NVivo 10.

Validation: The physician review identified only a few cases of disagreement with CDSS recommendations resulting in minor programming changes. When comparing the CDSS ouput with the SPSS program initial correlation/agreement was high. Discrepancies were examined and iterative changes were made to the code until perfect correlation/agreement was obtained.
Field testing: NPHWs and physicians used the CDSS to screen 227 and 65 adults respectively. NPHWs identified 57% (128/227) of patients to be at high CVD risk and referred them to the physician. Among those at high risk, 40% had a past history of CVD, 15% had a clinically high risk condition,13% had a calculated high CVD risk based on the algorithm, and 32% had diabetes or were identified at high risk of diabetes. Only 30% (37/128) of those recommended for referral actually visited a PHC clinic within one month of referral with 57% among them visiting the government PHC clinic and 43% visiting private clinics. Four key interview themes were identified: (1) Community participants, NPHWs and physicians found the tool intuitive and useful; (2) despite its high acceptability, several refinements (e.g. improved educational resources) were identified to optimize its ability to influence health care practices (3) competing priorities faced by PHC physicians and NPHWs are barriers to use; and (4) access to a doctor was a major barrier for patients identified at high risk;

Conclusions: A tablet based CDSS, integrated with existing PHC system could contribute to improved CVD detection, prevention and management in Indian primary health care system. Following refinements to the system, it will now be evaluated in a cluster randomized clinical trial involving 54 villages and 16000 people.

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