GROUP-1

PREPARED BY
2021YM05
PARAMESHWAR SAH
SOUTHER MEDICAL UNIVERSITY.

ESTIMATION OF CDSS(CLINICAL DIAGNOSIS SUPPORTING SYSTEM)

TECHNOLOGY USES IN TERTIARY HOSPITAL OF LMICS: A CROSS
SECTIONAL STUDY

BACKGROUND
CDSS is a new application of AI(Artificial Intelligence).It is very useful in medical
health care to reduce the errors and increase the quality of it.As it is new,many
developed countries use it in full phase while lower income countries like Nepal and
Bhutan, Bangladesh ,Ethopia,Uganda,etc. are using it less due to less developement of
their information technology ,poverty and scarcity of skilled manpowers.

INTRODUCTION

Clinical Decision Support Systems (CDSSs) are tools that help physicians make clinical
decisions in order to improve clinical performance and patient care. There are numerous
advantages to implementing and using CDSSs, such as lowering the rate of misdiagnosis,
enhancing efficiency and patient care, and lowering the risk of medication-related errors.
One of the World Health Organization's (WHO) priority for strengthening Primary Health
Care (PHC) is the development of health information systems and digital technologies, to
which CDSS belongs. However, research on effective and relevant techniques to using CDSS
in hospitals in LMICs to promote PHC remain limited.
CDSS technology use in LMICs, due to the large patient to doctor ratio, may result into a
disrupted existing workflow because it doesn’t match the providers’ real world information
processing patterns as well as the need to interact externally with the EHR. Other challenges
posed by CDSS use include the requirement of a very high technological proficiency to use,
users develop manual workarounds that compromise data documentation, interoperability
challenges of integration of CDSS in other hospitals making it inefficient for high quality
systems to be disseminated and scaled among others.
Although quite a number of studies indicate that CDSS can leads to positive health outcomes,
care needs to be taken that LMICs are not left behind and that the health inequity gap is not
further widened. This study seeks to explore how CDSS can be effectively integrated into
hospitals in LMICs as well as the challenges and opportunities it presents for LMICs.
PROBLEM STATEMENT
Although it is very useful for LMIC, less hospitals are using it.
REARCH GAP
POVERTY IN LMIC,SCARCITY OF SKILLED MANPOWER,LESS KNOWLEDGE
ABOUT IT AMONG PEOPLE AND MONOPOLY OF DOCTORS.
HYPOTHESIS
CDSS IS NOT FULLY ACCEPTED IN HOSPITALS OF LMIC .
RESEARCH QUESTIONS
1. ARE YOU ENJOYING USING CDSS?
2. WHAT IS THE RATE OF USE OF CDSS IN YOUR HOSPITAL?
3. WHAT PERCENTAGE OF DEPARTMENTS ARE USING IT?
4. HOW MANY DOCTORS ARE USING IT?
5. HOW MANY CDSS SUPPORTING DEVICES YOU HAVE?
OBJECTIVES:
1. TO FIND OUT THE RATE OF USE OF CDSS IN HOSPITALS OF LMIC.
2. TO GUESS THEIR INTEREST ABOUT IT.
3. WHAT ARE THE SUITABLE PERSONS FOR USE IT.
4. TO CHECK AVAILABILTY OF CDSS DEVICES.
5. TO FINF OUT MAIN VILIONS FOR OBSTRUCTING IN USE OF IT.
EXPECTED OUTCOME
After the completion of this reaserch we are able to understand about the condtion of
CDSS(in percentage OR rate)

PRELIMINARY LITERATURE REVIEW

Whereas CDSS has positively impacted on health care, several challenges / weaknesses have
been reported by the studies. This section explores some of the weaknesses that CDSS
technology has presented
User acceptance has been identified as one of the potential reasons as to why healthcare
providers don’t use CDSS. The American Informatics Association (AMIA) in the
publication, The Roadmap for National Action on Clinical Decision Support acknowledged
six strategic objectives divided into three main pillars for achieving widespread adoption of
effective clinical decision support system capabilities. The three main pillars were; High
Adoption and Effective Use, Best Knowledge Available When Needed and Continuous
Improvement of Knowledge and CDSS Methods(1).
However, from the three pillars stated above, there were challenges that countered the
adoption of CDSS and these are as follows;
Context factors; Context is the idea where a system is capable of interacting with the user and
the application itself. A system in a bid to provide context makes assumptions about the
present situation and relevance dependent on the patient’s status or user’s task. The most
important context factors found were the severity of the effect, clinical status of the patient,
complexity of the case and risk factor of the patient would add context when trigger related
contexts like start treatment and dose adjustment were included(2). However, clinicians
without including the said context factors, they relied on a patient’s drug list and triggers such
as start of treatment and dose adjustment making integrated medication CDSS unable to
correctly interpret the simple contexts of medication orders and a huge possibility of
medication errors(3).
Alert fatigue also defined as mental fatigue experienced by health care providers who
encounter several alerts and reminders from the use of CDSS. As a result of alert fatigue,
physicians are more likely to override 49%-96% of the current medication safety alerts from
basic to advanced medication related CDSS due to low specificity, unnecessary workflow
disruption and unclear information(4).
Triggers; these are one of the functional dimensions of CDSS and are the start of each clinical
rule. However, patient’s drug lists are the most used input data element, medication orders
play a key role in CDSS currently used.
Under the best knowledge available when needed, it contains three key challenges and these
include;
Integration in clinical workflow; Not thoroughly understanding the clinical workflow and
users’ wishes, there are lower probabilities of success as CDSS will not be integrated into
clinical workflow with no beneficial effect and will not be used(5).
Knowledge is available when needed. There is a challenge of keeping the clinical rules up to
date which is also time and money consuming hindering effective CDSS adaptation(6).
Today many clinical rule repositories exist however none of them are fully functioning.
CDSS is seen as a threat by physicians to their clinical autonomy(7). In this paper, the
following weaknesses were identified; difficulty to align with the complex workflow and its
very costly to adopt, maintain and support. Secondly physicians reported that it took them a
long time to document using CDSS which was inefficient. Thirdly some CDSSs are
standalone software systems that lack interoperability which means they cannot be integrated
with electronic health records (EHRs). Furthermore two studies reported that through using
CDSS, less communication was made between the physician and their patients and lastly
CDSS use led to an increase in unnecessary referrals.
In order to low middle income country has more necessary to apply the clinical decision
support system in the medical sector for patient diagnosis and treatment because it has helped
to doctor and nurse as well as patient parties for easy and effectively cure of disease like as
Watson for Oncology has been implemented in several different settings, including Brazil,
China, India, South Korea, and Mexico. By focusing on the implementation of an AI-based
clinical decision support system for oncology, it is a more beneficial for cancer management
globally and particularly for low-middle–income countries.(8)
To Increase access of medical service in community level of low middle income countries we
should be applied to the artificial intelligence system which will make an easy and fast
effectively should provide the all health service for all community people because it has been
helping to community health worker for collection of evidence base data in real patient
which data analysing to medical expert person and they would have been helped us to what
kinds of health delivery service should be implemented in community rural area of low
middle income countries peoples for enhanced of their health status.(9)
CDSSS is a best opportunity to strength and improve of maternal, neonatal and child health
as well as it will reduce of morbidity and mortality rate in low middle-income country. In
developing countries, especially women and child health has been going to decline condition
in rural community area whereas don't reach and access of properly health service as well as
appliances so those area used to mobile apps for providing the health services in easy and
fast. Like as fourth antenatal check-ups, maternal health delivery service in the institutional
delivery services, postnatal health check-ups, child immunization services, maternal and child
nutrition monitoring and follow up so many services gain and improve by CDSS. (10)
In order to persist of primary health care system in the low middle-income countries has
should be upgraded health service due to adopt the modern scientific technologies like as
CDSS. CDSS has a good scope in the LMICs for medical sector to disease diagnosis and
treatment aspect like in dispensary, health laboratory, and diagnostic appliance to enhance of
health providing services. Specially remote and rural communities where crises of technical
health man power there were helped to its technologies.(11)
Low middle-income countries have an implementation of a CDSS accompanied by training
seminars had a positive effect on the practices of physicians, increasing the proportion of
patients receiving appropriate prophylaxis for Venous thromboembolism. A clinical decision
support system has implemented for venous thromboembolism prophylaxis at a general
hospital in a middle-income country. Venous thromboembolism comprises two related
conditions deep-vein thrombosis and pulmonary embolism and is responsible for a great
number of complications in hospitalized patients.(12)

Therefore, CDSS has most important in the low middle income countries which further
future will brightness for assist the various types of disease to diagnosis and treatment system
especially developing countries where are a less of technical manpower as well as very low
and poor condition of health indicator due to wrong practice of recording and reporting
system, high burden of patient flow in hospital or health institution, crises of skill full human
resources so many problems has replaced by CDSS system so in order to the LMICs has
been more opportunities in theirs.
A paradigm shift in healthcare management has been brought about by clinical decision
support systems. Even though using CDSS lessens errors in medical diagnosis and treatment,
adoption is not as high as anticipated. A plausible explanation for the technology's slower
adoption could be the possibility of security risks or data breaches for CDSS. The
implementation of CDSS in hospitals could pose a risk to the security of patient information
(13).
A clinical decision support system (CDSS) can now offer feedback on quality indicators and
treatment suggestions based on patient-specific data, guidelines, knowledge, stratification
tools, and machine learning algorithms as a result of the growth of big data. The daily
adoption of CDSS has decreased due to clinicians' perceived risk and intent to use
CDSS(14) .
Even then only a few private hospitals and specific primary healthcare services have the
CDSS implemented in LMICs. In addition, the low acceptance rate of CDSS among
physicians and the paucity of resources such as computers, energy, the internet, and computer
expertise among healthcare providers may impede uptake of CDSS, (15). According to an
Australian study, 69% of respondents believe that a major impediment to the adoption of
SDSS is a lack of technical training and knowledge (16) Respondents (63%) also thought that
the system's usability was hampered by end users' lack of trust and confidence in its
information.
Clinical decision support technologies can affect doctors in both good and bad ways (7). The
drawback is that some doctors claim it took them a long time and that the CDSS didn't know
how to relate to their patients, so they talked to them less. This can lead to an increase in
pointless referrals. The kind of healthcare facility significantly affects the adoption of CDSS.
Additionally, it was determined that time restrictions and a lack of faith in the CDSS's
content were obstacles to its implementation in some healthcare settings.
Over all, CDSS may be subject to regulatory changes or requirements that could impact their
use or effectiveness and may face pushback from clinicians who prefer to make decisions
based on their own experience and judgement. There are also anticipated threat that CDSS
may be subject to data breaches or other security risks which we didn’t reviewed because is
beyond the scope of our research title.

RESEARCH DESIGN

INCLUSION AND EXCLUSION CRITERIA FOR LITERATURE REVIEW

Inclusion: peer reviewed articles that are published under the topic of healthcare, health
information system, usability and clinical decision support system. Articles type: systematic
review, Clinical trials and meta-analysis are included.
Exclusion: non-English language, publications on CDSS software development

1.Diagram showing inclusion and exclusion of articles.

Article searched
Pubmed=1,085
 n= 1,096
Year of publication
English language
Open access and articles
systematic
Review reviews
articles

n= 87

Irrelevant articles
excluded

n= 63 articles for
scoping review

Methods and Materials

The study will device ONLY DESCRIPTIVE method approach to assess the RATE of
CDSS in Ethiopia, Nepal and Uganda. To evaluate the patient outcome, we collect
electronic health record data before and after the implementation of CDSS. The assessment
study unit is hospitals in the country and each the study population is hospital administrators
and one doctor in charge of medical out-patient of the hospital. In Ethiopia there are
functional 410 hospitals (367 public hospitals and 43 private). In Nepal there are 491
hospitals (379 private hospitals and 112 public hospitals). In Uganda there are 201 functional
hospitals (52 public hospitals and 149 private hospitals)
We have calculated the number of hospitals according to Yamane's formula.
n = N / (1 + N(e^2))
n= calculated sample size
N=total number of hospitals in the country
e= desired level of precision at (0.05)
 2. Sample Size
S.No Country Total No. hospitals Sample size
1. Ethiopia 410 202
2. Nepal 491 220
3. Uganda 201 136

We apply computer based simple random method to select exact name of hospitals from
each country. We conduct self-administered question to each hospital CEO/medical director
and doctor in charge of OPD. For qualitative data we conduct in-depth interview to policy
makers of each country.
Data collection methods
We develop self-administered questionnaire to collect the survey data to the hospital
managers and OPD in charge doctors. We conduct pilot test to the questionnaire for face and
content validity before we apply. We use epidata 3.3.1 version software for data collection.
Check for data duplication and missed data. Then export to SPSS for data analysis. Develop
question Train data collectors and have SOP for both data collect
ors and data managers.
3.Table showing type of sampling and sample frame.

First stage Second stage

Proportionate
Convenience Purposive Purposive
stratified Study
sampling sampling sampling
sampling
tertiary
Ethiopia all
hospital administrative
directo
  Nepal   tertiary all unit  
Uganda tertiary all

4.Results of questionare-
country no.of question say say no percentage of yes
yes
Ethopia 101 101 50
Nepal 110 110 50
Uganda 68 68 50

Data analysis
TOTAL NO. OF YES ANSWER:101+110+68=279
TOTAL NO.OF QUESTIONS : 202+220+136=558.
RATE OF YES QUESTION=279/558X100=50%
RESULT
This results show only 50% people using CDSS in LMIC.
OUTCOME
To clrarify our outcome for further research,we compare it with SWORT and we reach in
conclusion that CDSS data can easily we find in hospital of LIMC.To support it we take dath
rate of patient in hospital and compare with SWORT and find strength is strong,weakness is
less,opportunity is good it is relevant and testable
For this we take indicators like safety.One study say that the use of CDSS in nepal decraese
90% death in hospital so i think it is very help ful in medicine.To prove this we take data of
patient from two different hospital in Nepal in which one is using CDSS and another not
using CDSS.
CDSS USED Death rate CDSS NOT USED Death rate
TUTH 10% NAMS 90%

Result
use of CDSS decrease the mortality rate by 90%.
Discussion
Above result show that ,there is inequality in use of CDSS but it is familiar in almost half of
the hospitals.In some countries it is hunred percentage acceptable.So, we cannot say exactly it
is not present in LMIC which is limitation of descriptive study.In descriptive study sample
values are not reliable because when we select most probable sample but our ROI(REGION
OF INTEREST) NOT PRESENT THERE.
It is not hundred percent because following table show there is probability of sampling error
due to monopoloy of doctor,interest of community and resources of hospital.Our sampling is
convenience random sampling types so there is not good chance of result of PICOT sample
questions.

4. Table showing demography of sample and sampling methods.

 First stage Second stage
Proportionate
Convenience Purposive Purposive
stratified
sampling sampling sampling
sampling
L tertiary
Ethiopia all
M hospital administrative
I   Nepal   tertiary all unit  
C Uganda tertiary all
s

Timeline (1st July - 31st October, 2023)

Country

Jul-23

First week: Participant 2nd - & 3rd week: Data 4th week: Data cleaning
Ethiopia
recruitment collection and confirmation

  Aug-23

First week: Participant 2nd - & 3rd week: Data 4th week: Data cleaning
Nepal
recruitment collection and confirmation

  Sep-23

First week: Participant 2nd - & 3rd week: Data 4th week: Data cleaning
Uganada
recruitment collection and confirmation

Conclusion
This research is qualatative (descriptive )type.we take
convenience random sample collection technique so
there is probability of sample error although the
outcome is 90% in Nepal so We think most probable
research topic.

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