title: Impact of an electronic clinical decision support system on workflow in antenatal care: the QUALMAT eCDSS in rural health care facilities in Ghana and Tanzania.
abstract: BACKGROUND
  The implementation of new technology can interrupt established workflows in health care settings. The Quality of Maternal Care (QUALMAT) project has introduced an electronic clinical decision support system (eCDSS) for antenatal care (ANC) and delivery in rural primary health care facilities in Africa.
  
  
  OBJECTIVE
  This study was carried out to investigate the influence of the QUALMAT eCDSS on the workflow of health care workers in rural primary health care facilities in Ghana and Tanzania.
  
  
  METHODS
  A direct observation, time-and-motion study on ANC processes was conducted using a structured data sheet with predefined major task categories. The duration and sequence of tasks performed during ANC visits were observed, and changes after the implementation of the eCDSS were analyzed.
  
  
  RESULTS
  In 24 QUALMAT study sites, 214 observations of ANC visits (144 in Ghana, 70 in Tanzania) were carried out at baseline and 148 observations (104 in Ghana, 44 in Tanzania) after the software was implemented in 12 of those sites. The median time spent combined for all centers in both countries to provide ANC at baseline was 6.5 min [interquartile range (IQR) =4.0-10.6]. Although the time spent on ANC increased in Tanzania and Ghana after the eCDSS implementation as compared to baseline, overall there was no significant increase in time used for ANC activities (0.51 min, p=0.06 in Ghana; and 0.54 min, p=0.26 in Tanzania) as compared to the control sites without the eCDSS. The percentage of medical history taking in women who had subsequent examinations increased after eCDSS implementation from 58.2% (39/67) to 95.3% (61/64) p<0.001 in Ghana but not in Tanzania [from 65.4% (17/26) to 71.4% (15/21) p=0.70].
  
  
  CONCLUSIONS
  The QUALMAT eCDSS does not increase the time needed for ANC but partly streamlined workflow at sites in Ghana, showing the potential of such a system to influence quality of care positively.
authors: Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany; Navrongo Health Research Centre, Navrongo, Ghana.
authors: Nathan
authors: N
authors: Mensah
authors: Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany; Muhimbili University of Health and Allied Sciences (MUHAS), Directorate of Information and Communication Technology, Dar Es Salaam, Tanzania.
authors: Felix
authors: F
authors: Sukums
authors: Navrongo Health Research Centre, Navrongo, Ghana.
authors: Timothy
authors: T
authors: Awine
authors: Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany.
authors: Andreas
authors: A
authors: Meid
authors: Navrongo Health Research Centre, Navrongo, Ghana.
authors: John
authors: J
authors: Williams
authors: School of Public Health, University of Ghana, Legon Accra, Ghana.
authors: Patricia
authors: P
authors: Akweongo
authors: Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany.
authors: Jens
authors: J
authors: Kaltschmidt
authors: Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany.
authors: Walter E
authors: WE
authors: Haefeli
authors: Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany; antje.blank@med.uni-heidelberg.de.
authors: Antje
authors: A
authors: Blank
mesh_terms: D020000:Decision Support Systems, Clinical / Q000706:statistics & numerical data*; D017598:Efficiency, Organizational; D005869:Ghana; D006801:Humans; D008487:Medical History Taking; D010808:Physical Examination; D011295:Prenatal Care / Q000458:organization & administration*; D019035:Rural Health Services / Q000458:organization & administration*; D013636:Tanzania; D013997:Time Factors; D013996:Time and Motion Studies; D057188:Workflow
keywords: antenatal care; developing countries; electronic clinical decision support system; health care providers; rural setting; sequence of events; sub-Saharan Africa; workflow
references: Int J Med Inform. 2010 Mar;79(3):204-10
references: 20089444
references: Comput Inform Nurs. 2004 Nov-Dec;22(6):337-44
references: 15602303
references: Methods Inf Med. 2002;41(5):435-42
references: 12501817
references: BMC Med Inform Decis Mak. 2013;13:44
references: 23574764
references: JAMA. 1998 Oct 21;280(15):1339-46
references: 9794315
references: J Am Med Inform Assoc. 2010 Jan-Feb;17(1):25-33
references: 20064798
references: J Am Med Inform Assoc. 2007 Jul-Aug;14(4):415-23
references: 17460127
references: BMJ. 2003 Apr 19;326(7394):860-3
references: 12702622
references: Trop Med Int Health. 2012 Mar;17(3):300-7
references: 22151853
references: BMC Pregnancy Childbirth. 2012;12:70
references: 22823930
references: Health Aff (Millwood). 2009 Mar-Apr;28(2):w282-93
references: 19174390
references: Ann Emerg Med. 2009 Apr;53(4):462-468.e1
references: 19026466
references: Int J Qual Health Care. 2006 Dec;18(6):437-45
references: 17041232
references: J Am Med Inform Assoc. 1994 Mar-Apr;1(2):108-23
references: 7719793
references: J Am Med Inform Assoc. 2003 Jul-Aug;10(4):295-303
references: 12668697
references: PLoS One. 2014;9(9):e106416
references: 25180831
references: Qual Saf Health Care. 2010 Oct;19(5):e15
references: 20427312
references: J Am Med Inform Assoc. 2003 Nov-Dec;10(6):523-30
references: 12925543
references: Pharm World Sci. 2008 Dec;30(6):907-15
references: 18787975
references: BMC Pregnancy Childbirth. 2006 Jun 23;6:22
references: 16796749
references: Glob Health Action. 2014;7:24534
references: 25361721
references: Proc AMIA Symp. 2000;:833-7
references: 11080001
references: Methods Inf Med. 1998 Sep;37(3):294-301
references: 9787631
references: J AHIMA. 2008 Jan;79(1):64-5
references: 18254407
references: J Am Med Inform Assoc. 2007 Jan-Feb;14(1):29-40
references: 17068355
references: Rural Remote Health. 2012;12:2072
references: 22934936
references: J Am Med Inform Assoc. 2011 Sep-Oct;18(5):704-10
references: 21527407
references: J Am Med Inform Assoc. 2009 Nov-Dec;16(6):826-36
references: 19717802
references: AMIA Annu Symp Proc. 2006;:794-8
references: 17238450
references: J Am Med Inform Assoc. 2010 May-Jun;17(3):308-12
references: 20442149
references: BMJ. 2005 Apr 2;330(7494):765
references: 15767266
references: BMC Health Serv Res. 2013;13 Suppl 2:S3
references: 23819518
references: AMIA Annu Symp Proc. 2003;:150-4
references: 14728152
references: Methods Inf Med. 2003;42(3):190-8
references: 12874649
references: Int J Med Inform. 2010 Jun;79(6):e109-15
references: 18996736
references: Qual Saf Health Care. 2010 Oct;19(5):e26
references: 20378618
references: J R Soc Promot Health. 1999 Sep;119(3):180-4
references: 10518358
references: Int J Tuberc Lung Dis. 2008 Aug;12(8):921-7
references: 18647452
references: Health Aff (Millwood). 2010 Feb;29(2):244-51
references: 20348068
references: PLoS Med. 2010;7(8). pii: e1000319. doi: 10.1371/journal.pmed.1000319
references: 20711476