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TitleThe effect of a clinical decision-making mHealth support system on maternal and neonatal mortality and morbidity in Ghana: study protocol for a cluster randomized controlled trial.
AuthorsAmoakoh, HB; Klipstein-Grobusch, K; Amoakoh-Coleman, M; Agyepong, IA; Kayode, GA; Sarpong, C; Grobbee, DE; Ansah, EK
Publication Date4 Apr 2017
Date Added to PubMed5 Apr 2017
AbstractMobile health (mHealth) presents one of the potential solutions to maximize health worker impact and efficiency in an effort to reach the Sustainable Development Goals 3.1 and 3.2, particularly in sub-Saharan African countries. Poor-quality clinical decision-making is known to be associated with poor pregnancy and birth outcomes. This study aims to assess the effect of a clinical decision-making support system (CDMSS) directed at frontline health care providers on neonatal and maternal health outcomes. A cluster randomized controlled trial will be conducted in 16 eligible districts (clusters) in the Eastern Region of Ghana to assess the effect of an mHealth CDMSS for maternal and neonatal health care services on maternal and neonatal outcomes. The CDMSS intervention consists of an Unstructured Supplementary Service Data (USSD)-based text messaging of standard emergency obstetric and neonatal protocols to providers on their request. The primary outcome of the intervention is the incidence of institutional neonatal mortality. Outcomes will be assessed through an analysis of data on maternal and neonatal morbidity and mortality extracted from the District Health Information Management System-2 (DHIMS-2) and health facility-based records. The quality of maternal and neonatal health care will be assessed in two purposively selected clusters from each study arm. In this trial the effect of a mobile CDMSS on institutional maternal and neonatal health outcomes will be evaluated to generate evidence-based recommendations for the use of mobile CDMSS in Ghana and other West African countries., identifier: NCT02468310 . Registered on 7 September 2015; Pan African Clinical Trials Registry, identifier: PACTR20151200109073 . Registered on 9 December 2015 retrospectively from trial start date.
TitleAdvancing beyond the system: telemedicine nurses' clinical reasoning using a computerised decision support system for patients with COPD - an ethnographic study.
AuthorsBarken, TL; Thygesen, E; Söderhamn, U
JournalBMC medical informatics and decision making
Publication Date28 Dec 2017
Date Added to PubMed29 Dec 2017
AbstractTelemedicine is changing traditional nursing care, and entails nurses performing advanced and complex care within a new clinical environment, and monitoring patients at a distance. Telemedicine practice requires complex disease management, advocating that the nurses' reasoning and decision-making processes are supported. Computerised decision support systems are being used increasingly to assist reasoning and decision-making in different situations. However, little research has focused on the clinical reasoning of nurses using a computerised decision support system in a telemedicine setting. Therefore, the objective of the study is to explore the process of telemedicine nurses' clinical reasoning when using a computerised decision support system for the management of patients with chronic obstructive pulmonary disease. The factors influencing the reasoning and decision-making processes were investigated. In this ethnographic study, a combination of data collection methods, including participatory observations, the think-aloud technique, and a focus group interview was employed. Collected data were analysed using qualitative content analysis. When telemedicine nurses used a computerised decision support system for the management of patients with complex, unstable chronic obstructive pulmonary disease, two categories emerged: "the process of telemedicine nurses' reasoning to assess health change" and "the influence of the telemedicine setting on nurses' reasoning and decision-making processes". An overall theme, termed "advancing beyond the system", represented the connection between the reasoning processes and the telemedicine work and setting, where being familiar with the patient functioned as a foundation for the nurses' clinical reasoning process. In the telemedicine setting, when supported by a computerised decision support system, nurses' reasoning was enabled by the continuous flow of digital clinical data, regular video-mediated contact and shared decision-making with the patient. These factors fostered an in-depth knowledge of the patients and acted as a foundation for the nurses' reasoning process. Nurses' reasoning frequently advanced beyond the computerised decision support system recommendations. Future studies are warranted to develop more accurate algorithms, increase system maturity, and improve the integration of the digital clinical information with clinical experiences, to support telemedicine nurses' reasoning process.
TitleUsing Mobile Health to Support Clinical Decision-Making to Improve Maternal and Neonatal Health Outcomes in Ghana: Insights of Frontline Health Worker Information Needs.
AuthorsAmoakoh, HB; Klipstein-Grobusch, K; Grobbee, DE; Amoakoh-Coleman, M; Oduro-Mensah, E; Sarpong, C; Frimpong, E; Kayode, GA; Agyepong, IA; Ansah, EK
JournalJMIR mHealth and uHealth
Publication Date24 May 2019
Date Added to PubMed28 May 2019
AbstractDeveloping and maintaining resilient health systems in low-resource settings like Ghana requires innovative approaches that adapt technology to context to improve health outcomes. One such innovation was a mobile health (mHealth) clinical decision-making support system (mCDMSS) that utilized text messaging (short message service, SMS) of standard emergency maternal and neonatal protocols via an unstructured supplementary service data (USSD) on request of the health care providers. This mCDMSS was implemented in a cluster randomized controlled trial (CRCT) in the Eastern Region of Ghana. This study aimed to analyze the pattern of requests made to the USSD by health workers (HWs). We assessed the relationship between requests made to the USSD and types of maternal and neonatal morbidities reported in health facilities (HFs). For clusters in the intervention arm of the CRCT, all requests to the USSD during the 18-month intervention period were extracted from a remote server, and maternal and neonatal health outcomes of interest were obtained from the District Health Information System of Ghana. Chi-square and Fisher exact tests were used to compare the proportion and type of requests made to the USSD by cluster, facility type, and location; whether phones accessing the intervention were shared facility phones or individual-use phones (type-of-phone); or whether protocols were accessed during the day or at night (time-of-day). Trends in requests made were analyzed over 3 6-month periods. The relationship between requests made and the number of cases reported in HFs was assessed using Spearman correlation. In total, 5329 requests from 72 (97%) participating HFs were made to the intervention. The average number of requests made per cluster was 667. Requests declined from the first to the third 6-month period (44.96% [2396/5329], 39.82% [2122/5329], and 15.22% [811/5329], respectively). Maternal conditions accounted for the majority of requests made (66.35% [3536/5329]). The most frequently accessed maternal conditions were postpartum hemorrhage (25.23% [892/3536]), other conditions (17.82% [630/3536]), and hypertension (16.49% [583/3536]), whereas the most frequently accessed neonatal conditions were prematurity (20.08% [360/1793]), sepsis (15.45% [277/1793]), and resuscitation (13.78% [247/1793]). Requests made to the mCDMSS varied significantly by cluster, type of request (maternal or neonatal), facility type and its location, type-of-phone, and time-of-day at 6-month interval (P<.001 for each variable). Trends in maternal and neonatal requests showed varying significance over each 6-month interval. Only asphyxia and sepsis cases showed significant correlations with the number of requests made (r=0.44 and r=0.79; P<.001 and P=.03, respectively). There were variations in the pattern of requests made to the mCDMSS over time. Detailed information regarding the use of the mCDMSS provides insight into the information needs of HWs for decision-making and an opportunity to focus support for HW training and ultimately improved maternal and neonatal health.
TitleDesigning a mHealth clinical decision support system for Parkinson's disease: a theoretically grounded user needs approach.
AuthorsTimotijevic, L; Hodgkins, CE; Banks, A; Rusconi, P; Egan, B; Peacock, M; Seiss, E; Touray, MML; Gage, H; Pellicano, C; Spalletta, G; Assogna, F; Giglio, M; Marcante, A; Gentile, G; Cikajlo, I; Gatsios, D; Konitsiotis, S; Fotiadis, D
JournalBMC medical informatics and decision making
Publication Date19 Feb 2020
Date Added to PubMed23 Feb 2020
AbstractDespite the established evidence and theoretical advances explaining human judgments under uncertainty, developments of mobile health (mHealth) Clinical Decision Support Systems (CDSS) have not explicitly applied the psychology of decision making to the study of user needs. We report on a user needs approach to develop a prototype of a mHealth CDSS for Parkinson's disease (PD), which is theoretically grounded in the psychological literature about expert decision making and judgement under uncertainty. A suite of user needs studies was conducted in 4 European countries (Greece, Italy, Slovenia, the UK) prior to the development of PD_Manager, a mHealth-based CDSS designed for Parkinson's disease, using wireless technology. Study 1 undertook Hierarchical Task Analysis (HTA) including elicitation of user needs, cognitive demands and perceived risks/benefits (ethical considerations) associated with the proposed CDSS, through structured interviews of prescribing clinicians (N = 47). Study 2 carried out computational modelling of prescribing clinicians' (N = 12) decision strategies based on social judgment theory. Study 3 was a vignette study of prescribing clinicians' (N = 18) willingness to change treatment based on either self-reported symptoms data, devices-generated symptoms data or combinations of both. Study 1 indicated that system development should move away from the traditional silos of 'motor' and 'non-motor' symptom evaluations and suggest that presenting data on symptoms according to goal-based domains would be the most beneficial approach, the most important being patients' overall Quality of Life (QoL). The computational modelling in Study 2 extrapolated different factor combinations when making judgements about different questions. Study 3 indicated that the clinicians were equally likely to change the care plan based on information about the change in the patient's condition from the patient's self-report and the wearable devices. Based on our approach, we could formulate the following principles of mHealth design: 1) enabling shared decision making between the clinician, patient and the carer; 2) flexibility that accounts for diagnostic and treatment variation among clinicians; 3) monitoring of information integration from multiple sources. Our approach highlighted the central importance of the patient-clinician relationship in clinical decision making and the relevance of theoretical as opposed to algorithm (technology)-based modelling of human judgment.
TitleTrial of telemedicine for patients on home ventilator support: feasibility, confidence in clinical management and use in medical decision-making.
AuthorsCasavant, DW; McManus, ML; Parsons, SK; Zurakowski, D; Graham, RJ
JournalJournal of telemedicine and telecare
Publication Date1 Dec 2014
Date Added to PubMed16 Oct 2014
AbstractWe investigated whether telemedicine (videoconferencing) was feasible in patients with special care needs on home ventilation, whether it affected the confidence of families about the clinical management of their child, and whether it supported clinical decision-making. Videoconferencing software was provided free for 14 families who had a computer and webcam. Families completed questionnaires about clinical management before the addition of telemedicine and 2-3 months after they had used telemedicine. They also completed a questionnaire about their experience with videoconferencing. There were 27 telemedicine encounters during the 9-month study. Families reported higher confidence in clinical care with telemedicine compared to telephone. They also reported that the videoconferencing was high-quality, easy to use, and did not increase their telecommunication costs. The telemedicine encounters supported clinical decision-making, especially in patients with active clinical problems or when the patient was acutely ill. The telemedicine encounters prevented the need for 23 clinic visits, three emergency room visits, and probably one hospital admission. Although the study was small, videoconferencing appears useful in the management of medically fragile patients on home ventilator support, producing high levels of family confidence in clinical management and value to clinicians in their decision-making.
TitlemHealth for Clinical Decision-Making in Sub-Saharan Africa: A Scoping Review.
AuthorsAdepoju, IO; Albersen, BJ; De Brouwere, V; van Roosmalen, J; Zweekhorst, M
JournalJMIR mHealth and uHealth
Publication Date23 Mar 2017
Date Added to PubMed25 Mar 2017
AbstractIn a bid to deliver quality health services in resource-poor settings, mobile health (mHealth) is increasingly being adopted. The role of mHealth in facilitating evidence-based clinical decision-making through data collection, decision algorithms, and evidence-based guidelines, for example, is established in resource-rich settings. However, the extent to which mobile clinical decision support systems (mCDSS) have been adopted specifically in resource-poor settings such as Africa and the lessons learned about their use in such settings are yet to be established. The aim of this study was to synthesize evidence on the use of mHealth for point-of-care decision support and improved quality of care by health care workers in Africa. A scoping review of 4 peer-reviewed and 1 grey literature databases was conducted. No date limits were applied, but only articles in English language were selected. Using pre-established criteria, 2 reviewers screened articles and extracted data. Articles were analyzed using Microsoft Excel and MAXQDA. We retained 22 articles representing 11 different studies in 7 sub-Saharan African countries. Interventions were mainly in the domain of maternal health and ranged from simple text messaging (short message service, SMS) to complex multicomponent interventions. Although health workers are generally supportive of mCDSS and perceive them as useful, concerns about increased workload and altered workflow hinder sustainability. Facilitators and barriers to use of mCDSS include technical and infrastructural support, ownership, health system challenges, and training. The use of mCDSS in sub-Saharan Africa is an indication of progress in mHealth, although their effect on quality of service delivery is yet to be fully explored. Lessons learned are useful for informing future research, policy, and practice for technologically supported health care delivery, especially in resource-poor settings.
TitleThe effect of an mHealth clinical decision-making support system on neonatal mortality in a low resource setting: A cluster-randomized controlled trial.
AuthorsAmoakoh, HB; Klipstein-Grobusch, K; Agyepong, IA; Zuithoff, NPA; Amoakoh-Coleman, M; Kayode, GA; Sarpong, C; Reitsma, JB; Grobbee, DE; Ansah, EK
Publication Date1 Jul 2019
Date Added to PubMed8 Aug 2019
AbstractMHealth interventions promise to bridge gaps in clinical care but documentation of their effectiveness is limited. We evaluated the utilization and effect of an mhealth clinical decision-making support intervention that aimed to improve neonatal mortality in Ghana by providing access to emergency neonatal protocols for frontline health workers. In the Eastern Region of Ghana, sixteen districts were randomized into two study arms (8 intervention and 8 control clusters) in a cluster-randomized controlled trial. Institutional neonatal mortality data were extracted from the District Health Information System-2 during an 18-month intervention period. We performed an intention-to-treat analysis and estimated the effect of the intervention on institutional neonatal mortality (primary outcome measure) using grouped binomial logistic regression with a random intercept per cluster. This trial is registered at (NCT02468310) and Pan African Clinical Trials Registry (PACTR20151200109073). There were 65,831 institutional deliveries and 348 institutional neonatal deaths during the study period. Overall, 47 ∙ 3% of deliveries and 56 ∙ 9% of neonatal deaths occurred in the intervention arm. During the intervention period, neonatal deaths increased from 4 ∙ 5 to 6 ∙ 4 deaths and, from 3 ∙ 9 to 4 ∙ 3 deaths per 1000 deliveries in the intervention arm and control arm respectively. The odds of neonatal death was 2⋅09 (95% CI (1 ∙ 00;4 ∙ 38); p = 0 ∙ 051) times higher in the intervention arm compared to the control arm (adjusted odds ratio). The correlation between the number of protocol requests and the number of deliveries per intervention cluster was 0 ∙ 71 (p = 0 ∙ 05). The higher risk of institutional neonatal death observed in intervention clusters may be due to problems with birth and death registration, unmeasured and unadjusted confounding, and unintended use of the intervention. The findings underpin the need for careful and rigorous evaluation of mHealth intervention implementation and effects. Netherlands Foundation for Scientific Research - WOTRO, Science for Global Development; Utrecht University.
TitleTreatment of opioid use disorder during COVID-19: Experiences of clinicians transitioning to telemedicine.
AuthorsUscher-Pines, L; Sousa, J; Raja, P; Mehrotra, A; Barnett, M; Huskamp, HA
JournalJournal of substance abuse treatment
Publication Date1 Nov 2020
Date Added to PubMed8 Sep 2020
AbstractThe COVID-19 pandemic has transformed care delivery for patients with opioid use disorder (OUD); however, little is known about the experiences of front-line clinicians in the transition to telemedicine. This study described how, in the context of the early stages of the pandemic, clinicians used telemedicine for OUD in conjunction with in-person care, barriers encountered, and implications for quality of care. In April 2020, we conducted semistructured interviews with clinicians waivered to prescribe buprenorphine. We used maximum variation sampling. We used standard qualitative analysis techniques, consisting of both inductive and deductive approaches, to identify and characterize themes. Eighteen clinicians representing 10 states participated. Nearly all interview participants were doing some telemedicine, and more than half were only doing telemedicine visits. Most participants reported changing their typical clinical care patterns to help patients remain at home and minimize exposure to COVID-19. Changes included waiving urine toxicology screening, sending patients home with a larger supply of OUD medications, and requiring fewer visits. Although several participants were serving new patients via telemedicine during the early weeks of the pandemic, others were not. Some clinicians identified positive impacts of telemedicine on the quality of their patient interactions, including increased access for patients. Others noted negative impacts including less structure and accountability, less information to inform clinical decision-making, challenges in establishing a connection, technological challenges, and shorter visits. In the context of the pandemic, buprenorphine prescribers quickly transitioned to providing telemedicine visits in high volume; nonetheless, there are still many unknowns, including the quality and safety of widespread use of telemedicine for OUD treatment.
TitleA Practical Do-It-Yourself Recruitment Framework for Concurrent eHealth Clinical Trials: Identification of Efficient and Cost-Effective Methods for Decision Making (Part 2).
AuthorsLattie, EG; Kaiser, SM; Alam, N; Tomasino, KN; Sargent, E; Rubanovich, CK; Palac, HL; Mohr, DC
JournalJournal of medical Internet research
Publication Date29 Nov 2018
Date Added to PubMed1 Dec 2018
AbstractThe ability to successfully recruit participants for electronic health (eHealth) clinical trials is largely dependent on the use of efficient and effective recruitment strategies. Determining which types of recruitment strategies to use presents a challenge for many researchers. The aim of this study was to present an analysis of the time-efficiency and cost-effectiveness of recruitment strategies for eHealth clinical trials, and it describes a framework for cost-effective trial recruitment. Participants were recruited for one of 5 eHealth trials of interventions for common mental health conditions. A multipronged recruitment approach was used, including digital (eg, social media and Craigslist), research registry-based, print (eg, flyers and posters on public transportation), clinic-based (eg, a general internal medicine clinic within an academic medical center and a large nonprofit health care organization), a market research recruitment firm, and traditional media strategies (eg, newspaper and television coverage in response to press releases). The time costs and fees for each recruitment method were calculated, and the participant yield on recruitment costs was calculated by dividing the number of enrolled participants by the total cost for each method. A total of 777 participants were enrolled across all trials. Digital recruitment strategies yielded the largest number of participants across the 5 clinical trials and represented 34.0% (264/777) of the total enrolled participants. Registry-based recruitment strategies were in second place by enrolling 28.0% (217/777) of the total enrolled participants across trials. Research registry-based recruitment had a relatively high conversion rate from potential participants who contacted our center for being screened to be enrolled, and it was also the most cost-effective for enrolling participants in this set of clinical trials with a total cost per person enrolled at US $8.99. On the basis of these results, a framework is proposed for participant recruitment. To make decisions on initiating and maintaining different types of recruitment strategies, the resources available and requirements of the research study (or studies) need to be carefully examined.
TitleMedical Help-Seeking Strategies for Perinatal Women With Obstetric and Mental Health Problems and Changes in Medical Decision Making Based on Online Health Information: Path Analysis.
AuthorsChung, K; Cho, HY; Kim, YR; Jhung, K; Koo, HS; Park, JY
JournalJournal of medical Internet research
Publication Date4 Mar 2020
Date Added to PubMed5 Mar 2020
AbstractPrevious studies have revealed that most pregnant women rarely discuss informal information found on the internet with health professionals and have frequently expressed concerns for medical experts' reactions to the online information they shared, as well as the lack of time to consult the medical experts in general. To date, little information is available on the effect of individual differences in utilizing medical help-seeking strategies on their medical decisions during the perinatal period. The objectives of this study were (1) to determine associations among perinatal women's medical help-seeking strategies, changes in medical decision making, and online health information utilization with a focus on the mediating effect of self-efficacy in perinatal health literacy on the intent to consult health professionals, and (2) to clarify these associations in perinatal women with two different medical problems: obstetric and mental health. A total of 164 perinatal women aged 24 to 47 years (mean 34.64, SD 3.80) repeatedly completed the Problem Solving in Medicine and Online Health Information Utilization questionnaires to examine the moderating effect of two types of medical problems on their decision-making processes. To validate the hypothesized relationships in the proposed conceptual model encompassing obstetric and mental health problem-solving models, path analyses were performed. This study found that some perinatal women, who use an online informal medical help-seeking (OIMH) strategy, would be more likely to change their medical decisions based only on internet-based information without consulting health professionals (P<.001), compared to other women using different medical help-seeking strategies. Particularly, this concern is significantly prevalent when encountering obstetric problems during the perinatal period (obstetric problem-solving: P<.001; mental health problem-solving: P=.02). Furthermore, perinatal women with mental health issues using the OIMH strategy showed a significant difference in intent to consult health professionals based on online health information when the medical problem they had to solve was different (obstetric problem-solving: P=.94; mental health problem-solving: P=.003). Despite the positive mediating effects of perinatal women's enhanced health literacy on the intent to discuss personal medical issues with health professionals based on online health information, the strategy used is of fundamental importance for understanding their help-seeking and decision-making processes during the perinatal period. Beyond a short consultation to steer patients quickly and authoritatively towards an obstetric doctor's choice of action, it is recommended in this study that obstetricians attempt to provide their patients with needed context for the information found online. To fully explain this information with an open mind, they should actively develop or support information and communications technology (ICT)-based health information services.
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