international journal of medical informatics 79 ( 2 0 1 0 ) 204–210 journal homepage: www.intl.elsevierhealth.com/journals/ijmi Changing course to make clinical decision support work in an HIV clinic in Kenya Sheraz F. Noormohammad a,b , Burke W. Mamlin b,c , Paul G. Biondich b,c , Brian McKown b , Sylvester N. Kimaiyo d,e , Martin C. Were b,c,* a IUPUI School of Informatics, Indianapolis, IN, USA b Regenstrief Institute Inc., Indianapolis, IN, USA c Indiana University School of Medicine, Indianapolis, IN, USA d Moi University School of Medicine, Eldoret, Kenya e USAID-Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya article info Article history: Received 21 September 2009 Received in revised form 22 December 2009 Accepted 4 January 2010 Keywords: Electronic medical record Clinical decision support Developing countries Technology adoption abstract Purpose: We implemented computer-based reminders for CD4 count tests at an HIV clinic in Western Kenya though an open-source Electronic Medical Record System. Within a month, providers had stopped complying with the reminders. Methods: We used a multi-method qualitative approach to determine reasons for failure to adhere to the reminders, and took multiple corrective actions to remedy the situation. Results: Major reasons for failure of the reminder system included: not considering delayed data entry and pending test results; relying on wrong data inadvertently entered into the system; inadequate training of providers who would sometimes disagree with the reminder suggestions; and resource issues making generation of reminders unreliable. With appropri- ate corrective actions, the reminder system has now been functional for over eight months. Conclusion: Implementing clinical decision support in resource-limited settings is chal- lenging. Understanding and correcting root causes of problems related to reminders will facilitate successful implementation of the decision support systems in these settings. © 2010 Elsevier Ireland Ltd. All rights reserved. 1. Introduction The HIV epidemic affects nearly 33 million people globally with two thirds of all HIV infected living in sub-Saharan Africa [1]. The large numbers of HIV-positive patients impose fur- ther strains to already overburdened healthcare systems [2]. In these settings, the few clinical facilities are often understaffed and under-resourced. Due to the vast shortage of doctors and other highly qualified personnel, care in many HIV-clinics is typically offered by a mid-level cadre of staff such as nurses and clinical officers. Further, there are high attrition rates of ∗ Corresponding author at: 410 West 10th Street, Suite 2000, Indianapolis, IN 46202-3012, USA. Tel.: +1 317 423 5540; fax: +1 317 423 5695. E-mail address: mwere@regenstrief.org (M.C. Were). the healthcare providers [3]. For HIV-positive patients these systemic shortcomings usually translate to poor quality of care and adverse patient outcomes. Approaches are needed to improve the quality of care offered to patients in resource-limited settings. It will take time for governments to train enough providers to adequately take care of all the patients. In the meantime, the many sick patients have to be cared for. The approach adopted should also be one that helps to specifically assist less-trained clini- cians as they take care of patients. Electronic medical record systems (EMRs) have been shown to improve efficiency and quality of care offered. In fact, the Institute of Medicine identi- 1386-5056/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijmedinf.2010.01.002