title: The feasibility of automating audit and feedback for ART guideline adherence in Malawi.
abstract: OBJECTIVE
  To determine the feasibility of using electronic medical record (EMR) data to provide audit and feedback of antiretroviral therapy (ART) clinical guideline adherence to healthcare workers (HCWs) in Malawi.
  
  
  METHODS
  We evaluated recommendations from Malawi's ART guidelines using GuideLine Implementability Appraisal criteria. Recommendations that passed selected criteria were converted into ratio-based performance measures. We queried representative EMR data to determine the feasibility of generating feedback for each performance measure, summed clinical encounters representing each performance measure's denominator, and then measured the distribution of encounter frequency for individual HCWs across nurse and clinical officer groups.
  
  
  RESULTS
  We analyzed 423,831 encounters in the EMR data and generated automated feedback for 21 recommendations (12%) from Malawi's ART guidelines. We identified 11 nurse recommendations and eight clinical officer recommendations. Individual nurses and clinical officers had an average of 45 and 59 encounters per month, per recommendation, respectively. Another 37 recommendations (21%) would support audit and feedback if additional routine EMR data are captured and temporal constraints are modeled.
  
  
  CONCLUSIONS
  It appears feasible to implement automated guideline adherence feedback that could potentially improve HCW performance and supervision. Feedback reports may support workplace learning by increasing HCWs' opportunities to reflect on their performance.
  
  
  CONCLUSIONS
  A moderate number of recommendations from Malawi's ART guidelines can be used to generate automated guideline adherence feedback using existing EMR data. Further study is needed to determine the receptivity of HCWs to peer comparison feedback and barriers to implementation of automated audit and feedback in low-resource settings.
authors.affiliation: Department of Biomedical Informatics, Center for Health Informatics for Underserved, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, USA. zjl1@pitt.edu
authors.forename: Zach
authors.initials: Z
authors.lastname: Landis Lewis
authors.forename: Claudia
authors.initials: C
authors.lastname: Mello-Thoms
authors.forename: Oliver J
authors.initials: OJ
authors.lastname: Gadabu
authors.forename: E Miranda
authors.initials: EM
authors.lastname: Gillespie
authors.forename: Gerald P
authors.initials: GP
authors.lastname: Douglas
authors.forename: Rebecca S
authors.initials: RS
authors.lastname: Crowley
mesh_terms: D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D001330:Electronic Data Processing; D057286:Electronic Health Records; D005240:Feasibility Studies; D005246:Feedback; D019983:Guideline Adherence; D006282:Health Personnel; D006801:Humans; D008295:Malawi; D008485:Medical Audit / Q000379:methods*; D017410:Practice Guidelines as Topic
chemical_list: D044966:Anti-Retroviral Agents