Table 1 Features critical to success of electronic decision support[14] and corresponding characteristics of the QUALMAT CDSS development

General system features

Integration with charting or order entry system to support workflow integration

The system supports the workflow of ANC visits in guiding the nurse step by step through the process.

The structure of the system is streamlined with the antenatal care cards which are the main documentation for pregnant women in these areas.

The delivery process is followed dynamically, designed according to the present workflow.

Use of a computer to generate the decision

QUALMAT CDSS is computer based and will be operated from laptops at the health care facility.

Women who are overdue for antenatal care can be identified automatically and contacted.

Clinicial system interaction feature

Automatic provision of decision support as part of clinician workflow

Use of laptops dedicated to the QUALMAT software covers all regular and also unscheduled antenatal care visits, delivery, and the first 24h after delivery. Decision support is issued to the care provider for all relevant decisions during these visits.

No need for additional clinician data entry

This was not attempted because the ANC cards currently need to be completed in parallel (in case the woman delivers elsewhere). Printout of the cards is currently not implemented albeit possible as soon as printing infrastructure becomes available.

Request documentation of the reason for not following CDSS recommendations

If critical actions (e.g. laboratory tests, preventive measures) are not carried out the reason will be documented (e.g. patient’s refusal, missing equipment, other reason).

Provision of decision support at time and location of decision making

The mobile laptops can be used in any room of the health care center and decision support is therefore supported at the point of care.

Recommendations executed by noting agreement

Recommended actions during patient visits are marked as done or not done in the system. In addition, on a summary page at the end of each visit care providers are asked to indicate their agreement (or disagreement) with the proposed actions.

Communication content features

Provision of a recommendation, not just an assessment

If situations of concern are detected the system provides detailed and explicit instructions on how to proceed.

Promotion of action rather than inaction

Specific actions are proposed such as referral of a patient, drug application, or interventions.

Justification of decision support via provision of reasoning

Recommendations can be instantly accessed through links to WHO and local guidelines integrated in the system.

Justification of decision support via provision of research evidence

Decision support is based on WHO and local guidelines. Because the provision of a scientific text appeared not to add benefit in a rural African environment, the provision of straightforward and user-friendly WHO guidelines was deemed appropriate.

Auxiliary features

Local user involvement in development process

Local users were involved in each step of planning and during all test phases of the prototype and the release candidates.

Provision of decision support results to patients as well as providers

Patients will not directly see the results of the decision support, e.g. printouts, because the logistics in the given environment do not yet allow for this.

However, providers are always able to review previous and current decisions suggested by the system.

CDSS accompanied by periodic performance feedback

CDSS is linked to a performance based incentives scheme. Users will receive regular performance feedback, where data from the CDDS are the major but not the only valuation source for the assessment.

CDSS accompanied by conventional education

Extensive training workshops have been held on general and specific computer use. During these workshops guidelines on maternal care were also part of the training schedule.