Medical Decision Support Systems in Africa

G. Bediang, C. O. Bagayoko, A. Geissbuhler Department of Radiology and Medical Informatics, Geneva University, Switzerland

cision support in health as «an inter- Summary Introduction active, user-controlled system (usually Objective: To present an overview of the current state of computer- The scope of medical decision support computer-based software) that are based medical decision support systems in Africa in the areas of systems has evolved over time. Initially designed specifically to facilitate the public health, patient care, and consumer support. based on models of deductive logic decision maker (health administrators Methods: Scientific and gray literature reviews complemented by ex- (clinical algorithm), Bayesian prob- or clinician) in using data, models, and pert interviews. abilistic, heuristic, analytical models knowledge elements to solve semi- Results: Various domains of decision support are developed and and expert systems - the “Greek Ora- structured and complex decision ». deployed in Sub-Saharan Africa: public health information systems, cle” [1, 2] model, the first systems of This definition, therefore, includes clinical decision-support systems, and patient-centred decision- decision support were mainly focused the efficiency of decision making (di- support systems. on computer-aided diagnosis in medi- agnosis, treatment) in the clinical en- Conclusions: Until recently, most of these systems have been decine. These systems were based prima- vironment but also in the broader ployed by international organizations without a real ownership rily on theories of clinical reasoning. field of healthcare and health. It ar- policy entrusted to the African stakeholders. Many of these endeav- The practitioner would enter the data gues that all stakeholders in the health ours have remained or ceased at the experimentation stage. The mul- collected from the patient in a system system (health professionals, manag- tiplicity of organizations has led to the deployment of fragmented

and wait for it to provide the correct ers, policy makers) should have the in- systems causing serious interoperability problems. In addition to diagnosis [2]. Although these ap- formation needed to improve the man- basic infrastructures, these studies also highlight the importance of proaches were very innovative, they agement of patients, services and health good organization, training and support, as key to the success and were not used widely. In order to in- system, respectively [15]. In addition, sustainability of these decision support systems. crease their clinical usability, diagnos- this new approach also incorporates tic decision-support systems have direct support of patients by them- Keywords evolved into integrated systems in the selves [13]. Decision support system, Africa, telemedicine, eHealth, mHealth work environment and processes [2] In Africa the decision support is in- used by practitioners “in order to limit creasingly integrated into health systems, Yearb Med Inform 2010:47-54 the amount of data that clinicians must as there is a growing demand for infor- re-enter across isolated systems” and mation to help policy building, health provide timely assistance to the deci- systems planning and monitoring. The sion-making process based on the clini- impact of health programs in order to cal information of patients [3]. The achieve the Millennium Development concept of decision-support has wid- Goals [16, 17] cannot be neglected. In ened to encompass computerized pa- addition, given the propagating crisis of tient records, general medical knowl- health professionals (insufficient pro- edge base information resources and fessionals, inadequate distribution, applications for diagnosis, medical brain drain, etc...), the development of prescription and the interpretation of information technology and telecommu- test results, as well as alerting and re- nications offers new opportunities for de- minder systems [3-12]. cision support through access to remote Furthermore, the concept of sup- expertise for professionals located in porting the clinician with patients’ isolated areas [18]. diagnosis and therapy has evolved The objective of this review is to into an approach that also integrates present a critical overview of the cur- the support of managers and policy rent state of decision support systems makers in their decisions for patient in Africa in the areas of public health, populations [13]. Tan [14], illustrates patient care, and consumer decision- this change in approach, defining de- support.

IMIA Yearbook of Medical Informatics 2010 48 Bediang et al.

Methodology Design, Operation and Challenges of this vast amount of information needs DHIS to be captured by health professionals A literature search was performed themselves has resulted in the perception through MEDLINE and over the World Apart from South Africa, where the of their workload having increased. Health Organization’s databases: WHO process of setting up a DHIS has sprung Moreover, the information collected was headquarters library database (WHOLIS) from national interests involving often redundant [20, 25-27]. and WHO-AFRO Library (AFROLIB, stakeholders and national research or- Another set of difficulties relates to African Index Medicus). Papers de- ganizations [23], the majority of DHIS resources allocated for the operation of scribing implemented systems in projects in Africa have been driven by DHIS. Staffing of DHIS was often in- Sub-Saharan Africa were reviewed. international agencies and donors [19, adequate. Most of them had little or no Additional information and material 20]. Under international pressure and training and so lacked competent skills was obtained through interviews of given the time constraints for these to ensure its optimal performance [20, experts in the field of e-health and projects, the design of DHIS was lim- 25]. The managers were not suffi- medical informatics involved in de- ited to central levels, and implementa- ciently supported in their activities cision-support systems implementation would be carried out without in- when using the application. Teams also tions in Africa. volving all stakeholders. These aspects gave it less attention due to weak fi- have been very important because the nancial resources, insufficient equip- sustainability of DHIS has depended ment and infrastructure [20, 25]. heavily on the ability of national and The availability and accessibility of local authorities to maintain these ac- data produced by the DHIS were not Decision Support Systems for tivities. However, the DHIS was mainly guaranteed for various groups and us- Public Health in Africa designed for the collection of patient ers of this information in the district, data, thus relegating to a secondary and as result, this information has been Background and Objectives level the administrative data collection frequently underutilized. Managers and

and management of human and mate- health care professionals have not used In the late 1980’s, prompted by in- rial resources [19, 20]. it to inform, improve or monitor health ternational agencies and donors, pi- In the health systems of most Afri- programs in the district. Moreover, there lot projects for implementing District can countries, there is a multiplicity of was no analysis and use at the point of Health Information Systems (DHIS) international actors. These organizations collection. There was virtually no feed- were launched in African countries have developed many vertical programs back from the district health service to [19]. Far from being mere tools for like tuberculosis, immunization, HIV / health centers. Even if these feedbacks routine collection of data, the DHIS AIDS and the prevention of mother- were reported, there is often the prob- were designed with the objective of to-child transmission of HIV / AIDS lem of consistency between the infor- improving the health of populations [24, 25] supporting the existence of a mation provided and the real needs of within a health district [20]. Health multitude of records and various forms. the managers [20, 25]. Other barriers districts should, therefore, be Several difficulties impeding the proper to the use of the data were also identi- equipped with systems able to col- functioning of DHIS and the quality fied: the constant changes in staff and lect, analyze and interpret data in of data have emerged from the studies poor communication of knowledge, order to create locally relevant in- of such systems. insufficient information integration in formation [21]. As available, this in- The fragmentation of data from the the activities of the health district, information should be shared between decision support systems has often been adequate access to data denominator in different actors in the health system noted upon [24, 25]. This comes from order to calculate the indicators, the to be used for surveillance, monitor- the lack of information sharing between need for suitable technical, administra- ing, evaluation of effectiveness, the providers of care within a health dis- tive and political means and finally the impact of interventions and health trict, but also between institutions or risk of conflict of ideas or interference programs, planning and resource groups of users of such information, with political plans [22, 25]. management [20-22]. which are: public or private health Later, in the mid 1990’s, after re- institutions, local authorities, communi- forms of many health systems and un- ties and governments [24, 25]. The re- der the leadership of national research sult has been a frequent lack of coor- Information Quality organizations, other countries, such as dination, an unnecessary complexity In most studied systems, the data have South Africa, have initiated nationwide and duplication of data collection proc- been considered unreliable [20, 25, 26]. implementation of various DHIS esses and unsystematic or disorganized An evaluation for DHIS in Kenya has projects [23]. health policies. In addition, the fact that found that “information produced was

IMIA Yearbook of Medical Informatics 2010 49 Medical Decision Support Systems in Africa

30% accurate, 19% complete, 26% ability [21, 24]. Moreover, a satisfac- essary for the effective management of timely, 72% relevant, the level of con- tion survey of DHIS software in Tan- patients, health care services perform- fidentiality and use of information at zania [21, 24] demonstrates the high ance, planning and development of the point of collection stood at 32% and reliability of its data, although its us- health policies [21, 26]. 22 % respectively and information se- ability by health professionals is rela- Another important element is the curity at 48%” [20, 25, 26]. Another tively low. However, this study has need for an effective partnership be- study on a health information system noted the difficulty of the reproduc- tween different actors in the establish- on the mother-child transmission of tion and integration of information ment of an information system [20]. HIV, showed that the completeness or from the multitude of existing paper The various steps, which are the de- accuracy of the data varied depending forms in the DHIS application. An- sign, implementation and operation of on the nature of the data collected [26]. other study reveals the health profes- a DHIS, should involve all the stake- In addition, the completeness of the sionals’ lack of computer skills as an holders (i.e. designers, donors, produc- data does not mean they are automati- adverse factor [25]. Computerization ers and users) [19]. This participatory cally correct. A study of the data to cannot really improve the functioning approach has the advantage of ensur- monitor an Anti-Retro Viral (ARV) of a DHIS and users’ satisfaction un- ing shared ownership, and promotes treatment program in Malawi showed less there is an improvement in deal- institutionalization and sustainability. that, despite the fact that health facili- ing with the lack of technological in- Studies also recommend the use of ties had complete clinical and labora- frastructure [21, 30]. simpler data collection tools, the reduc- tory data in their registry, only 40% Sustainability of a DHIS is improved tion of the number of registers and the of them were accurate [28]. On the if it is supported by a centralized, so- definition of a limited set of key indi- other hand, it is noted that data on cial and organizational process [21] : cators which are shared by various ver- morbidity and mortality were often health professionals must understand tical programs [16, 32, 33]. This stream- adequate [20, 25, 26]. “why” the data are collected and “how” lining and simplification of the process In these information systems, data they are used [25]; training and sup- of collecting the data is as relevant as are collected in the registry of health port must be guaranteed [21, 24] in the decision to computerize the system services and then transmitted in form order to provide skills, including com- itself. It is therefore necessary to inte- of summaries to the district health au- puter literacy [25], as well as at least grate the information from existing thorities. This raises the problem of minimal knowledge on data analysis paper forms [24]. However, to fully data consistency because there is a large and interpretation [25]. assume its role as decision support tool discrepancy between the values of The challenge for the health systems in health, DHIS should allow the col- records and summaries of health fa- of all countries around the world is to lection of other data fields such as ad- cilities but the details between the positively optimize the management of ministrative and management informa- monthly summaries of health facilities health services (effectiveness, effi- tion (e.g., human resources, material and reports of district match perfectly ciency) [15]. Although there is a will resources, financial information). Also, [26]. Through this observation, the sug- in that direction, it is clear that most the DHIS could in addition involve the gestion is made that the problems in developing countries, particularly those collection of information on selected the integrity of the data originate in in Africa, have yet to make consider- determinants of health such as the the process of data collection and able investments in medical informa- availability of food, water, and sanita- analysis. Other studies find a discrep- tion systems to improve their health tion shelters [20]. ancy between data from local and na- care systems and their ability to make Identified in most studies, inadequate tional offices and point to the signifi- informed decisions [31]. There are infrastructure, equipment and financial cant under-reporting of data as the many constraints and difficulties to resources are factors impacting the per- factor [29]. overcome: the process for defining the formance of a DHIS. Moreover, insuf- basic needs for information, develop- ficiency in quantity and quality of hu- ment of standardized data collection, man resources is also an important Computerization and Quality of promotion of health informatics and factor. Thus, several authors have rec- training [21], as well as the develop- ommended in their work that a specific Information in the DHIS ment of a culture of information among staff be given the task of running the Most of the studied information sys- health professionals, managers and activities of the DHIS, not only to de- tems were only partially computerized. policy makers [21]. This culture of increase the workload for health profes- The computerization of the DHIS has formation is essential for the enhance- sionals but also to improve the quality been identified as a factor with the po- ment of information systems; it involves of data collected [21, 25, 28]. Manag- tential to improve the process of data the recognition of the value of data by ers and health professionals should be collection, analysis, storage and avail- all teams in different facilities, as nec- adequately trained and adapted [21, 24,

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26]. This training must be integrated opment and implementation on a large within the entire health system in the Clinical Decision Support scale in Africa have been possible perspective of overall social develop- Systems through the collaboration of many na- ment [21, 24, 26]. Even if the quality tional and international partners [43]. of training is essential for ameliorating Electronic Medical Records Systems Currently, OpenMRS is based prima- practices, we must nevertheless recog- (EMR Systems) rily on open source components. It uses nize that it must be combined with international standards and its data other elements to generate the maxi- In Africa, many countries are devoting model is based on a semantic diction- mum positive effect [21, 24, 26]. Train- much effort to set up EMR systems. ary specifically tailored for low-re- ing managers and health professionals The implementation of EMR systems source settings [35, 43, 44]. Most of in “computer literacy” has also been has been encouraged by the growing the data are structured and reported on found as an important instrument for need of governments, donors, profes- paper forms by health professionals. the proper working of a DHIS [21, 24, sionals and researchers to have reliable They are then collected to be entered 26]. They should also be supported and clinical data on the health care needs in the computer system [35, 43, 44]. supervised throughout all activities re- of populations correlated to insufficient OpenMRS has been designed to al- lated to the DHIS. resources [35]. low local health professionals monitor There is a renewed interest in the Thus, in 2001, with the participa- continuously the care provided to pa- large-scale deployment of DHIS, in tion of many international partners, the tients and adapt evolving strategies of particular through the Africa Health first experience of an African EMR care as needed [38]. This view assumes Infoway project [34]. Its main part- system was conducted in a rural health that the information generated must be ners are the International Telecommu- clinic in Kenya [36, 37]. Given the suc- returned to the care providers who are nication Union (ITU), the World cess of that project and the importance its original sources thus providing Health Organization, the African Un- and attention given to HIV/AIDS, that “clinical utility” [43]. This helps veri- ion and other interested local, national EMR systems has subsequently been fying that the collected information is and global entities. Established for modified to support specific treatment reliable and of good quality [43]. Thus, five years (2008-2013), this project of patients with HIV [38, 39]. Conse- for example, for HIV patients enrolled aims to develop and implement so- quently, several EMR systems projects in the OpenMRS program we can have lutions based on information tech- were then being carried out in many other an accurate fact about their number and nology to refine decision-making African nations [40-42], mainly in the distribution, the results of laboratory mechanism in the health districts of all field of HIV and associated diseases such tests made by them (i.e. CD4) and those African countries. as tuberculosis. Of all these ventures, who have started ARV treatment or who OpenMRS is currently the most pub- require additional one. From these lished system throughout the continent. data, the system is capable of generat- ing information and reports useful for Evaluation of DHIS practitioners to help improve their per- Many criteria have been identified and formance in the care of patients [38]. deemed important to evaluate a DHIS OpenMRS It becomes easy to identify new infec- and thus, increase its sustainability [21, In Africa, the first implementations of tions or side effects of medications. Pro- 23]. They should be taken into account EMR have been made with the web fessionals no longer have to worry about and be part of the process from its de- based EMR created by PIH (Partners the availability of data on patients [45]. sign to operation [19, 21]. First, in the In Health) for general care in primary Studies show that the provision of infor- design phase, a system analysis to guar- health care system [36, 37] or with MS- mation in an EMR system to the health antee the viability of DHIS before Access system for specific programs professionals has the ability to improve committing any resource for its devel- such as AMPATH [39]. OpenMRS is the quality of care [46], reduce medical opment or deployment should be un- an EMR system for developing coun- errors [47, 48] and unnecessary tests [49]. dertaken. Second, during the imple- tries with limited resources [35, 43]. It Patients who missed their appointments mentation, the evaluation would consist was designed as a flexible replacement can also be identified. With the aid of of monitoring the main criteria set in for these systems. It is based on MySQL, computerized reminders [50, 51] and the flowchart of the application in or- Java and the Tomcat application server. alerts, OpenMRS has allowed mobile der to pinpoint the errors and apply Its evolution has been marked by its teams, not only to identify affected adequate alterations. Finally, in the specific guidance on the care of patients patients but also the reasons for the fail- operation phase, it verifies the effec- with HIV and TB, and its increasing ure to administer appropriate solutions tiveness and impact of the DHIS in the ability to manage a growing number of and provide care for these patients ei- health system. observations of patients [43]. Its devel- ther at their homes or work places [38].

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This method has significantly improved cuses on installing and configuring soft- use of a system to access remote exper- patient adherence to treatment with ware and systems to meet the needs of tise. This is used to support profession- ARVs. It has also made possible to cre- a particular health system information als located in rural or isolated areas [18, ate links between HIV patients and their requirement with little or no program- 54]. In this context, the iPath platform community system, and have a more ming of the actual software.” This net- is one that has been most successfully comprehensive care. work’s aim has been to develop a genu- used in Africa. Moreover, additional modules help to ine community among developers and Developed at the University of Basel manage, for example, the stocks of ARV implementers through the different and accessible via the internet, iPath was drugs in pharmacies, or the substitution existing channels of communication initially designed to support diagnosis in feeding of pediatric patients [38]. and exchange like annual meetings, in- pathology, and has been expanded to Another important aspect was the ternship programs and a website. The other domains such as dermatology and integration of a search algorithm based OpenMRS implementers’ network also general medicine [55]. Different users on numerous parameters (name, ID had the opportunity to discuss and (experts and non-experts) meet in focus number, diagnosis) into OpenMRS with share their experience with their peers. groups based on their network affilia- a low failure rate for tracking patients The network has supported South Af- tion or their interests. Non-experts can registered in the system [43]. This fea- ricans in their experimentation [52], submit cases via the web (text, images) ture has been enhanced by the normali- thereby, reducing the perceived barri- and ask specific questions for experts. zation of captured data through a dic- ers to the implementation of EMR sys- Experts provide advice and answers to tionary of concepts [43, 44]. It makes tems in developing countries [48, 53]. questions asked by non-experts, and this the queries about patients easy, fast, and Another obstacle was to ensure the in a clinically useful time frame. The dis- adequate, thus improving the efficiency system’s evolution. The data model had cussions can synchronous or asynchro- of the workflow of care providers [45]. to be changed several times and the nous [55]. The continuity of the recorded pa- transaction function was also rebuilt This platform is used by the tient data, their availability and acces- and adjusted so the OpenMRS could Telemedicine Network in French sibility by multiple users are also con- support the growing number of patients Speaking Africa known as RAFT tributing to improve the performance and observations [48, 53]. Then, some (Réseau en Afrique Francophone pour of health professionals [45]. mechanisms were put in place to safe- la Télémédecine) for asynchronous However, this information should guard the reliability of coded data, se- teleconsultations from isolated care also be available for other stakeholders curity, confidentiality and data syn- professionals [18]. In order to deal with of the health care system such as manag- chronization because most of these data connectivity problems and with the ers, researchers and donors [45]. Through had been provided by remote sites as enormous workload of specialists, medi- regular reports such information can be paper forms [38, 43]. cal coordinators mediate the tele-exper- very helpful in planning and coordinat- In terms of flexibility, besides HIV tise requests, in order to identify and ing resources such as laboratory exams, and TB care, the code and infrastructure bring qualified professionals to discuss medications, human resources, infra- of OpenMRS should allow modifications and address the specific inquired clini- structure, and even logistics [38]. to support other types of care [43]. cal cases, thus improving response rate The implementation and deployment Although OpenMRS is an open and response time [18]. of OpenMRS in Africa have seen a lot source project, its implementation, Since 2002, iPath is also used as an of positive returns. These successes are management, expertise and the infra- application in a teledermatology project due to the involvement and collabora- structure required for its adaptation in rural South Africa, the Port St. Johns tion of many national and international and operation represent a significant project [54. 56, 57], and in the West institutional partners [35]. Such coop- burden. For the sustainability of such African Doctors and Healthcare Pro- eration has been fostered by the World programs, it is therefore, important to fessionals Network [56]. Health Organization [43]. Amongst the have an even broader participation of Using a different platform known challenges encountered, the first one all the partners of the health care sys- as telederm.org [58], “The Africa Tele- has been to ensure effective working tem (i.e. private or public, national or dermatology Project”, initially started relations and coordination between all international). in Uganda and currently covering coun- the institutional partners and develop- tries of Southern and Eastern Africa , ment teams involved in the process. is being expanded since 2007 [56]. Its Besides regular coordination meetings, Telemedicine for Decision Support in objective is to support African health developing a network of implement- professionals in the management of ers has been the engine of success [52]. Africa patients with skin diseases, especially Such team consists of “health infor- Unlike the EMR system, the decision those related to HIV/AIDS. It provides mation systems professional that fo- support in telemedicine is based on the assistance with remote diagnosis, edu-

IMIA Yearbook of Medical Informatics 2010 52 Bediang et al.

cational resources and support for research projects. Consumer Decision Support Discussion Systems Numerous studies demonstrate the potential of decision support tools for im- mHealth for Decision Support in Research has highlighted the willing- proving health care systems. Although Africa ness of patients to be involved in deci- the interest in electronic health care sys- sion making about their health and tems in African countries is recent, dif- With the development of mobile tech- healthcare [62] and the need for them ferent types of tools developed for im- nologies (smartphones, GPRS, 3G, and to access their medical records in or- proving medical decisions in the rest of WiMAX), mobile eHealth tools der to increase their participation in world are being used. These systems, as (mHealth) are being developed to sup- the process of their care for better out- well as telemedicine tools are relevant port healthcare professionals in Africa comes [63]. The decision support in solutions to some of the challenges fac- [59]. In South Africa, with the project this context, therefore, aims to assist ing the African health care plans. called Cell-Life project [59] where the the patients to make appropriate However, many specific problems focus is on HIV patients, health work- choices regarding their own health care still limit their widespread use. Among ers have real-time access, through mo- [64]. Given the poverty of the major- them: the relative lack of organization bile devices, to data recorded during ity of the populations and insufficient of the systems, inadequate infrastruc- their clinical or hospital visits. The in- health services in Africa, the trend is ture, shortage and the disparity of formation collected on the patients’ the development of systems that will health professionals, lack of technical condition is transmitted to a remote enable patients to maximize their abil- skills, language barriers, and the still high database managed by the caregiver. It ity for self reliance and avoid long proportion of illiterate populations. gets analyzed by the manager and the journeys which often entails unneces- These tools can be implemented suc- health worker receives feedback and sary costs. cessfully only by improving the basic the type of attitude to pursue, over the In this context, we have found in the infrastructure (supply of electricity and phone. literature a decision support system connectivity to the Internet) but also Another model was tested in re- developed in rural areas of South Af- through training of all stakeholders, mote areas of Kenya in 2002, using rica [65]. Based on primary care issued clinicians, managers, health care sys- satellite phones and Personal Digital for common diseases such as tubercu- tem decision makers, and, eventually, Assistants (PDA) to capture data losis, hypertension, bronchitis, the com- patients and citizens. Nevertheless, the about patients during the consultation puterized decision support system was wide adoption and use in the African and access clinical and prescription developed. This application allows the population of mobile technologies like databases. When needed, expertise is collect of data about the symptoms pro- cell phones, and long-distance, wire- sought from specialized centers in the vided by the patient in a structured way. less connectivity with Wimax have a USA. The evaluation of this system has It analyzes them and provides to pa- great potential for the diffusion and ac- confirmed its usefulness in the rapid tient, information on ways to access the cess to tools for decision support. These access to expertise, and also in ac- health care services. Rather than a di- technologies have the advantage of be- celerating the search for patient data, agnostic tool, it is actually an advisory ing cheaper than satellite, consume lit- the increase in the completeness of system where the main recommenda- tle energy, and are relatively easy to the information in facilitating the tion issued is whether or not to consult deploy. work, and ultimately in improving a health care professional [65]. Thus, it is important to drive good the quality of care [60]. Also in South Africa, a system of evaluation studies in Africa on the de- Another project using mobile tech- sending reminders via SMS through cision support systems. Taking into ac- nologies for decision support in Africa mobile phone for well-defined periods, count the specific problems of Africa, is taking place in Uganda: the Uganda was used as an alternative to the “Di- these assessments are intended to bet- Health Information Network [59, 61]. rectly observed therapy system” for ter adapt existing solutions for enhanced The project involves the digitization of patients’ participation in the treatment use and sustainability. local and international guidelines of tuberculosis [66]. adapted to the context. Then, these data However, it is important to note that are integrated into Personal Digital As- the usefulness of such systems is most References sistants (PDAs) and distributed to health obvious when patients are faced with professionals for decision support. complex decisions [67, 68]. At the cur- 1. Miller RA, Masarie FE. The demise of the “Greek Oracle” model for medical diagnostic systems. 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IMIA Yearbook of Medical Informatics 2010