US Centers for Disease Control and Prevention-Division of Global HIV/AIDS, Nairobi, Kenya.
Int J Med Inform. 2012 Oct;81(10):e83-92. doi: 10.1016/j.ijmedinf.2012.07.010. Epub 2012 Aug 24.
It is estimated that one million people infected with HIV initiate anti-retroviral therapy (ART) in resource-constrained countries annually. This occurs against a background of overburdened health workers with limited skills to handle rapidly changing treatment standards and guidelines hence compromising quality of care. Electronic medical record (EMR)-based clinical decision support systems (CDSS) are considered a solution to improve quality of care. Little evidence, however, exists on the effectiveness of EMR-based CDSS on quality of HIV care and treatment in resource-constrained settings.
The aim of this systematic review was to identify original studies on EMR-based CDSS describing process and outcome measures as well as reported barriers to their implementation in resource-constrained settings. We characterized the studies by guideline adherence, data and process, and barriers to CDSS implementation.
Two reviewers independently assessed original articles from a search of the MEDLINE, EMBASE, CINAHL and Global Health Library databases until January 2012. The included articles were those that evaluated or described the implementation of EMR-based CDSS that were used in HIV care in low-income countries.
A total of 12 studies met the inclusion criteria, 10 of which were conducted in sub-Saharan Africa and 2 in the Caribbean. None of the papers described a strong (randomized controlled) evaluation design. Guideline adherence: One study showed that ordering rates for CD4 tests were significantly higher when reminders were used. Data and process: Studies reported reduction in data errors, reduction in missed appointments, reduction in missed CD4 results and reduction in patient waiting time. Two studies showed a significant increase in time spent by clinicians on direct patient care. Barriers to CDSS implementation: Technical infrastructure problems such as unreliable electric power and erratic Internet connectivity, clinicians' limited computer skills and failure by providers to comply with the reminders are key impediments to the implementation and effective use of CDSS.
The limited number of evaluation studies, the basic and heterogeneous study designs, and varied outcome measures make it difficult to meaningfully conclude on the effectiveness of CDSS on quality of HIV care and treatment in resource-limited settings. High quality evaluation studies are needed. Factors specific to implementation of EMR-based CDSS in resource-limited setting should be addressed before such countries can demonstrate its full benefits. More work needs to be done to overcome the barriers to EMR and CDSS implementation in developing countries such as technical infrastructure and care providers' computer illiteracy. However, simultaneously evaluating and describing CDSS implementation strategies that work can further guide wise investments in their wider rollout.
据估计，每年有 100 万人在资源有限的国家开始接受抗逆转录病毒疗法（ART）。这是在卫生工作者负担过重、技能有限的情况下发生的，他们难以应对快速变化的治疗标准和指南，从而影响了护理质量。基于电子病历（EMR）的临床决策支持系统（CDSS）被认为是提高护理质量的一种解决方案。然而，在资源有限的环境中，基于 EMR 的 CDSS 对 HIV 护理和治疗质量的影响的证据很少。
本系统评价的目的是确定描述基于 EMR 的 CDSS 的原始研究，这些研究描述了过程和结果指标，并报告了在资源有限的环境中实施这些指标的障碍。我们通过指南依从性、数据和流程以及 CDSS 实施的障碍来对这些研究进行了描述。
两位审查员独立评估了从 MEDLINE、EMBASE、CINAHL 和全球卫生图书馆数据库中搜索到的原始文章，直到 2012 年 1 月。纳入的文章是那些评估或描述在低收入国家用于 HIV 护理的基于 EMR 的 CDSS 实施的文章。
共有 12 项研究符合纳入标准，其中 10 项研究在撒哈拉以南非洲进行，2 项在加勒比地区进行。没有一篇论文描述了强有力的（随机对照）评估设计。指南依从性：一项研究表明，使用提醒时，CD4 检测的开单率显著提高。数据和流程：研究报告了数据错误减少、错过预约减少、错过 CD4 结果减少和患者等待时间减少。两项研究表明，临床医生用于直接患者护理的时间显著增加。CDSS 实施的障碍：技术基础设施问题，如不可靠的电力和不稳定的互联网连接、临床医生有限的计算机技能以及提供者不遵守提醒等，是 CDSS 实施和有效使用的关键障碍。
评估研究数量有限、基本和异构的研究设计以及不同的结果测量使得很难对资源有限环境中 CDSS 对 HIV 护理和治疗质量的有效性进行有意义的总结。需要高质量的评估研究。在资源有限的国家能够展示其全部效益之前，应该解决基于 EMR 的 CDSS 实施中的特定因素。需要做更多的工作来克服发展中国家实施电子病历和 CDSS 的障碍，如技术基础设施和护理人员的计算机文盲。然而，同时评估和描述有效的 CDSS 实施策略可以进一步指导明智地投资于其更广泛的推广。
