Health-E-Net Limited, Nairobi, Kenya; Institute of Public Health, University of Heidelberg, Germany.
Institute of Healthcare Management, Strathmore Business School, Nairobi, Kenya.
Int J Med Inform. 2018 Jun;114:121-129. doi: 10.1016/j.ijmedinf.2017.10.014. Epub 2017 Oct 23.
The United Nations' Sustainable Development Goal #3.8 targets 'access to quality essential healthcare services'. Clinical practice guidelines are an important tool for ensuring quality of clinical care, but many challenges prevent their use in low-resource settings. Monitoring the use of guidelines relies on cumbersome clinical audits of paper records, and electronic systems face financial and other limitations. Here we describe a unique approach to generating digital data from paper using guideline-based templates, rubber stamps and mobile phones.
The Guidelines Adherence in Slums Project targeted ten private sector primary healthcare clinics serving informal settlements in Nairobi, Kenya. Each clinic was provided with rubber stamp templates to support documentation and management of commonly encountered outpatient conditions. Participatory design methods were used to customize templates to the workflows and infrastructure of each clinic. Rubber stamps were used to print templates into paper charts, providing clinicians with checklists for use during consultations. Templates used bubble format data entry, which could be digitized from images taken on mobile phones. Besides rubber stamp templates, the intervention included booklets of guideline compilations, one Android phone for digitizing images of templates, and one data feedback/continuing medical education session per clinic each month. In this paper we focus on the effect of the intervention on documentation of three non-communicable diseases in one clinic.
Seventy charts of patients enrolled in the chronic disease program (hypertension/diabetes, n=867; chronic respiratory diseases, n=223) at one of the ten intervention clinics were sampled. Documentation of each individual patient encounter in the pre-intervention (January-March 2016) and post-intervention period (May-July) was scored for information in four dimensions - general data, patient assessment, testing, and management. Control criteria included information with no counterparts in templates (e.g. notes on presenting complaints, vital signs). Documentation scores for each patient were compared between both pre- and post-intervention periods and between encounters documented with and without templates (post-intervention only).
The total number of patient encounters in the pre-intervention (282) and post-intervention periods (264) did not differ. Mean documentation scores increased significantly in the post-intervention period on average by 21%, 24% and 17% for hypertension, diabetes and chronic respiratory diseases, respectively. Differences were greater (47%, 43% and 27%, respectively) when documentation with and without templates was compared. Changes between pre- vs.post-intervention, and with vs.without template, varied between individual dimensions of documentation. Overall, documentation improved more for general data and patient assessment than in testing or management.
The use of templates improves paper-based documentation of patient care, a first step towards improving the quality of care. Rubber stamps provide a simple and low-cost method to print templates on demand. In combination with ubiquitously available mobile phones, information entered on paper can be easily and rapidly digitized. This 'frugal innovation' in m-Health can empower small, private sector facilities, where large numbers of urban patients seek healthcare, to generate digital data on routine outpatient care. These data can form the basis for evidence-based quality improvement efforts at large scale, and help deliver on the SDG promise of quality essential healthcare services for all.
联合国可持续发展目标 3.8 旨在“获得优质基本医疗服务”。临床实践指南是确保临床护理质量的重要工具，但许多挑战阻止了它们在资源匮乏的环境中使用。监测指南的使用依赖于对纸质记录进行繁琐的临床审计，而电子系统则面临财务和其他限制。在这里，我们描述了一种从纸质文件中生成数字数据的独特方法，该方法使用基于指南的模板、橡皮图章和移动电话。
贫民窟中遵循指南项目针对的是在内罗毕肯尼亚为非正规住区服务的 10 家私营部门初级保健诊所。每个诊所都提供橡皮图章模板，以支持常见门诊疾病的文件记录和管理。采用参与式设计方法使模板适应每个诊所的工作流程和基础设施。橡皮图章用于将模板打印到病历上，为临床医生提供咨询期间使用的检查表。模板使用气泡格式的数据输入，可以通过移动电话拍摄的图像进行数字化。除了橡皮图章模板外，干预措施还包括指南汇编手册、一部用于每月对每个诊所的模板图像进行数字化的 Android 手机，以及每月一次的数据反馈/继续医学教育会议。在本文中，我们重点介绍了干预措施对一个诊所的三种非传染性疾病的记录的影响。
从十个干预诊所中的一个慢性病计划（高血压/糖尿病，n=867；慢性呼吸道疾病，n=223）中抽取了 70 份患者病历。在干预前（2016 年 1 月至 3 月）和干预后（2016 年 5 月至 7 月）期间，对每个患者的每次就诊记录进行评分，以评估四个维度的信息——一般数据、患者评估、检查和管理。控制标准包括模板中没有对应的信息（例如，主诉记录、生命体征）。比较了两个干预前和干预后时期以及有和没有模板记录的就诊（仅在干预后）之间的每个患者的记录得分。
干预前（282 次）和干预后（264 次）的就诊次数没有差异。高血压、糖尿病和慢性呼吸道疾病的平均记录评分在干预后分别显著增加了 21%、24%和 17%。当比较有和没有模板的记录时，差异更大（分别为 47%、43%和 27%）。与预干预相比，与模板相关的记录在记录一般数据和患者评估方面有较大的改善，而在测试或管理方面的改善则较小。
模板的使用提高了纸质病历的记录质量，这是提高护理质量的第一步。橡皮图章提供了一种简单且低成本的按需打印模板的方法。结合无处不在的移动电话，在纸上输入的信息可以轻松快速地进行数字化。这种移动医疗领域的“节俭创新”可以为寻求医疗服务的大量城市患者提供小型私营部门设施生成常规门诊护理的数字数据。这些数据可以为大规模的循证质量改进工作提供基础，并有助于实现可持续发展目标中为所有人提供优质基本医疗服务的承诺。
