Computerized “clinical decision support systems” (CDSS): their potential for improving HIV follow-up in low-resource settings
3 May, 13 | by Leslie Goode, Blogmaster
Kit Fairley (http://sti.bmj.com/content/87/Suppl_2/ii25.full) in this journal offers an overview of the many ways in which information technology can be used in the area of STIs. This is most obviously through the role of electronic medical records (EMR); but also through the possibility these offer for clinical decision support systems that can be used to generate prompts and reminders. Information Technology (IT) has also opened up possibilities such as computer assisted self-interviewing (http://sti.bmj.com/content/86/4/310.abstract?sid=07f1ed96-1c3f-4a99-9da5-58f02157ea9e), provision of wider access to counselling services, facilitation of partner notification. If Gaydos et al. are on the right track (http://www.iwantthekit.org), IT may one day “completely change the way services are provided”. A number of papers published by STIs have focussed on trialling short message system reminders for re-testing/re-screening. These have been show to have some effectiveness in the area of Chlamydia screening (http://sti.bmj.com/content/89/1/11.abstract?sid=07f1ed96-1c3f-4a99-9da5-58f02157ea9e; http://sti.bmj.com/content/89/1/16.abstract?sid=07f1ed96-1c3f-4a99-9da5-58f02157ea9e; http://sti.bmj.com/content/87/Suppl_1/A258.3.abstract?sid=07f1ed96-1c3f-4a99-9da5-58f02157ea9e) and in the area of MSM HIV retesting achieved a fourfold increase in uptake (http://sti.bmj.com/content/87/3/229.abstract?sid=07f1ed96-1c3f-4a99-9da5-58f02157ea9e).
A recent randomized control (RCT) study from a USAID-funded paediatric referral clinic in Kenya (Were & Vreeman), however, points to one impressively fruitful application of IT to STIs which seems to have failed to attract the attention it deserves (http://pediatrics.aappublications.org/content/131/3/e789.abstract?sid=f4698a8a-9724-4227-8896-3a9f57f92729). In limited resource settings the complex process of pediatric HIV follow-up seems particularly apt to benefit from EMRs that can generate prompts to clinicians – especially where such staff are less than adequately trained, or are subject to high rates of turn-over, or overwhelmed by patient demand. The reminders generated through this clinical decision support system (CDSS) include PCR tests, CD4 tests, ARV reminders, as well as baseline chemistry & hematology studies, chest X-rays and malnutrition reminders. The RCT study claims a nearly fourfold improvement in adherence to protocols overall – admittedly with some procedures (e.g. chest x-rays, laboratory tests other than ELISA) benefiting enormously more than others (e.g. initiation of ART ). Of course, the effectiveness of such reminders, as the authors emphasize, ultimately depends on the quality of the input data informing the “summaries” from which reminders are generated.
The effectiveness of CDSS in this area seems less remarkable than the apparent absence of studies like that of Were & Vreeman. The authors cite studies of the use of computer-based alerts and reminders for HIV care in the US, and a comparative study between 2 clinics of a system of computer-generated reminders for CD4 testing of adults. But, “rigorously controlled trials of CDSS effectiveness in resource-limited settings could not be found”. The authors conclude that pediatric HIV care in limited resource settings is one area where the application of technology has the potential dramatically to improve compliance with protocols. Such a claim seems to warrant further investigation.