A Community-Based, Mobile Electronic Medical Record System App for High-Quality, Integrated Antiretroviral Therapy in Lilongwe, Malawi: Design Process and Pilot Implementation

"We have been so patient because we know where we are coming from" Exploring the acceptability and feasibility of a mobile electronic medical record system designed for community-based antiretroviral therapy in Lilongwe, Malawi

Background

Mobile health (mHealth) is reshaping healthcare delivery, especially in HIV management. The World Health Organization advocates for mHealth to provide healthcare workers (HCWs) with real-time data, enhancing patient care. However, in Malawi's Lighthouse Trust antiretroviral therapy (ART) clinic, the nurse-led community-based ART (NCAP) program faces hurdles with data management due to lack of access to electronic medical records systems (EMRS) in the community setting. EMRS is not typically available in differentiated service delivery settings where reliable power and internet are often unavailable. We used human-centered design (HCD) processes to create a mobile EMRS prototype, the Community-based ART Retention and Suppression (CARES) app. We explore progress to simplify workflow for HCWs and improve client care.

Methods

To evaluate the CARES app's feasibility and acceptability among NCAP HCWs, we conducted in-depth interviews among 15 NCAP HCWs. We used a rapid qualitative analysis approach guided by the extended Technology Acceptance Model. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Results

As a likely result of HCD, HCWs demonstrated high expectations for the CARES app to improve healthcare delivery and data management. However, challenges such as app performance, data integration, and system navigation were significant barriers to acceptance or feasibility. Despite challenges, HCWs remained optimistic about the potential for CARES to enhance NCAP clinical decision-making and data flow. HCWs emphasized the need for continuous training and stakeholder engagement, improved infrastructure, data security protections, and establishing the CARES app and EMRS integration to facilitate CARES' longterm success at scale.

Conclusion

The study's findings underscore the importance of HCD for mHealth buy-in. As HCWs were invested in CARES success, they remained optimistic that the app could enhance NCAP services if user experience and app performance improved. Incorporation of HCW feedback would help deliver beyond the promise of CARES.

Crossing the digital divide: The workload of manual data entry for integration between mobile health applications and eHealth infrastructure

Background

Many digital health interventions (DHIs), including mobile health (mHealth) apps, aim to improve both client outcomes and efficiency like electronic medical record systems (EMRS). Although interoperability is the gold standard, it is also complex and costly, requiring technical expertise, stakeholder permissions, and sustained funding. Manual data linkage processes are commonly used to "integrate" across systems and allow for assessment of DHI impact, a best practice, before further investment. For mHealth, the manual data linkage workload, including related monitoring and evaluation (M&E) activities, remains poorly understood.

Methodology

As a baseline study for an open-source app to mirror EMRS and reduce healthcare worker (HCW) workload while improving care in the Nurse-led Community-based Antiretroviral therapy Program (NCAP) in Lilongwe, Malawi, we conducted a time-motion study observing HCWs completing data management activities, including routine M&E and manual data linkage of individual-level app data to EMRS. Data management tasks should reduce or end with successful app implementation and EMRS integration. Data was analysed in Excel.

Results

We observed 69:53:00 of HCWs performing routine NCAP service delivery tasks: 39:52:00 (57%) was spent completing M&E data related tasks of which 15:57:00 (23%) was spent on manual data linkage workload, alone.

Conclusion

Understanding the workload to ensure quality M&E data, including to complete manual data linkage of mHealth apps to EMRS, provides stakeholders with inputs to drive DHI innovations and integration decision making. Quantifying potential mHealth benefits on more efficient, high-quality M&E data may trigger new innovations to reduce workloads and strengthen evidence to spur continuous improvement.

Patient-provider experiences with chronic non-communicable disease care during COVID-19 lockdowns in rural Uganda: A qualitative analysis

Non-communicable diseases (NCDs) are a growing health burden in Sub-Saharan Africa and especially Uganda, where they account for over one third of all deaths. During the COVID-19 pandemic, public health control measures such as societal "lockdowns" had a significant impact on longitudinal NCD care though no studies have looked at the lived experience around NCD care during the pandemic. Our objective was to understand the experience of NCD care for both patients and providers in southwestern Uganda during the COVID-19 pandemic. We conducted in-depth, in-person qualitative interviews with 20 patients living with hypertension, diabetes, and/or cardiac disease purposefully selected from the outpatient clinics at Mbarara Regional Referral Hospital and 11 healthcare providers from public health facilities in Mbarara, southwestern Uganda. We analyzed transcripts according to conventional content analysis. We identified four major themes that emerged from the interviews; (1) difficulty accessing medication; (2) food insecurity; (3) barriers to the delivery of NCD clinical care and (4) alternative forms of care. Pre-existing challenges with NCD care were exacerbated during COVID-19 lockdown periods and care was severely disrupted, leading to worsened patient health and even death. The barriers to care were exacerbations of underlying systemic problems with NCD care delivery that require targeted interventions. Future work should leverage digital health interventions, de-centralizing NCD care, improving follow-up, providing social supports to NCD patients, and rectifying supply chain issues.