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Background: Health care organizations increasingly depend on business intelligence tools, including "dashboards," to capture, analyze, and present data on performance metrics. Ideally, dashboards allow users to quickly visualize actionable data to inform and optimize clinical and organizational performance. In reality, dashboards are typically embedded in complex health care organizations with massive data streams and end users with distinct needs. Thus, designing effective dashboards is a challenging task and theoretical underpinnings of health care dashboards are poorly characterized; even the concept of the dashboard remains ill-defined. Researchers, informaticists, clinical managers, and health care administrators will benefit from a clearer understanding of how dashboards have been developed, implemented, and evaluated, and how the design, end user, and context influence their uptake and effectiveness., Objective: This scoping review first aims to survey the vast published literature of "dashboards" to describe where, why, and for whom they are used in health care settings, as well as how they are developed, implemented, and evaluated. Further, we will examine how dashboard design and content is informed by intended purpose and end users., Methods: In July 2020, we searched MEDLINE, Embase, Web of Science, and the Cochrane Library for peer-reviewed literature using a targeted strategy developed with a research librarian and retrieved 5188 results. Following deduplication, 3306 studies were screened in duplicate for title and abstract. Any abstracts mentioning a health care dashboard were retrieved in full text and are undergoing duplicate review for eligibility. Articles will be included for data extraction and analysis if they describe the development, implementation, or evaluation of a dashboard that was successfully used in routine workflow. Articles will be excluded if they were published before 2015, the full text is unavailable, they are in a non-English language, or they describe dashboards used for public health tracking, in settings where direct patient care is not provided, or in undergraduate medical education. Any discrepancies in eligibility determination will be adjudicated by a third reviewer. We chose to focus on articles published after 2015 and those that describe dashboards that were successfully used in routine practice to identify the most recent and relevant literature to support future dashboard development in the rapidly evolving field of health care informatics., Results: All articles have undergone dual review for title and abstract, with a total of 2019 articles mentioning use of a health care dashboard retrieved in full text for further review. We are currently reviewing all full-text articles in duplicate. We aim to publish findings by mid-2022. Findings will be reported following guidance from the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist., Conclusions: This scoping review will provide stakeholders with an overview of existing dashboard tools, highlighting the ways in which dashboards have been developed, implemented, and evaluated in different settings and for different end user groups, and identify potential research gaps. Findings will guide efforts to design and use dashboards in the health care sector more effectively., International Registered Report Identifier (irrid): DERR1-10.2196/34894., (©Danielle Helminski, Jacob E Kurlander, Anjana Deep Renji, Jeremy B Sussman, Paul N Pfeiffer, Marisa L Conte, Oliver J Gadabu, Alex N Kokaly, Rebecca Goldberg, Allison Ranusch, Laura J Damschroder, Zach Landis-Lewis. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 02.03.2022.)

Setting: Eighty-three villages without electricity in Mtema Traditional Authority, Lilongwe District, Malawi. Objectives: To describe 1) the expansion of the electronic village register (EVR) to 83 villages in Mtema Traditional Authority, 2) the challenges encountered and changes made to render the system robust and user-friendly, 3) the value propositions developed to increase the system's desirability, and 4) the results of the village register. Design: Descriptive study. Results: After the deployment of the EVR in one village in 2013, the system was extended to 83 villages with modifications to render it more robust and user-friendly. These changes included modifications to the power, connectivity and work stations, better battery security and a single modular electronics panel. Value propositions of the EVR for the village headmen included daily postings of news/sports items and sockets for charging mobile phones and lanterns. Of the 47 559 residents registered, 48% were male, 14% were aged 0-4 years, 43% were aged 15-44 years and 4% were aged ⩾65 years. Between 1 April 2016 and 31 March 2017, 976 births and 177 deaths were recorded. The total equipment cost per village was US$2430. Conclusion: An electronic village birth and death registration system can function in an area with no communication or electricity infrastructure., Competing Interests: Conflicts of interest: none declared.

Background: Adherence to antiretroviral therapy (ART) is crucial to preventing mother-to-child transmission of human immunodeficiency virus (HIV) and ensuring the long-term effectiveness of ART, yet data are sparse from African routine care programs on maternal adherence to triple ART., Methods: We analyzed data from women who started ART at 13 large health facilities in Malawi between September 2011 and October 2013. We defined adherence as the percentage of days "covered" by pharmacy claims. Adherence of ≥90% was deemed adequate. We calculated inverse probability of censoring weights to adjust adherence estimates for informative censoring. We used descriptive statistics, survival analysis, and pooled logistic regression to compare adherence between pregnant and breastfeeding women eligible for ART under Option B+, and nonpregnant and nonbreastfeeding women who started ART with low CD4 cell counts or World Health Organization clinical stage 3/4 disease., Results: Adherence was adequate for 73% of the women during pregnancy, for 66% in the first 3 months post partum, and for about 75% during months 4-21 post partum. About 70% of women who started ART during pregnancy and breastfeeding adhered adequately during the first 2 years of ART, but only about 30% of them had maintained adequate adherence at every visit. Risk factors for inadequate adherence included starting ART with an Option B+ indication, at a younger age, or at a district hospital or health center., Conclusions: One-third of women retained in the Option B+ program adhered inadequately during pregnancy and breastfeeding, especially soon after delivery. Effective interventions to improve adherence among women in this program should be implemented., (© The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America.)

Setting: Patients with chronic non-communicable diseases attending a primary health care centre, Lilongwe, Malawi., Objective: Using an electronic medical record monitoring system, to describe the quarterly and cumulative disease burden, management and outcomes of patients registered between March 2014 and June 2015., Design: A cross-sectional study., Results: Of 1135 patients, with new registrations increasing each quarter, 66% were female, 21% were aged ⩾65 years, 20% were obese, 53% had hypertension alone, 18% had diabetes alone, 12% had asthma, 10% had epilepsy and 7% had both hypertension and diabetes. In every quarter, about 30% of patients did not attend the clinic and 19% were registered as lost to follow-up (not seen for ⩾1 year) in the last quarter. Of those attending, over 90% were prescribed medication, and 80-90% with hypertension and/or diabetes had blood pressure/blood glucose measured. Over 85% of those with epilepsy had no seizures and 60-75% with asthma had no severe attacks. Control of blood pressure (41-51%) and diabetes (15-38%) was poor., Conclusion: It is feasible to manage patients with non-communicable diseases in a primary health care setting in Malawi, although more attention is needed to improve clinic attendance and the control of hypertension and diabetes.

Background: Studies of Malawi's option B+ programme for HIV-positive pregnant and breastfeeding women have reported high loss to follow-up during pregnancy and at the start of antiretroviral therapy (ART), but few data exist about retention during breastfeeding and after weaning. We examined loss to follow-up and retention in care in patients in the option B+ programme during their first 3 years on ART., Methods: We analysed two data sources: aggregated facility-level data about patients in option B+ who started ART between Oct 1, 2011, and June 30, 2012, at 546 health facilities; and patient-level data from 20 large facilities with electronic medical record system for HIV-positive women who started ART between Sept 1, 2011, and Dec 31, 2013, under option B+ or because they had WHO clinical stages 3 or 4 disease or had CD4 counts of less than 350 cells per μL. We used facility-level data to calculate representative estimates of retention and loss to follow-up. We used patient-level data to study temporal trends in retention, timing of loss to follow-up, and predictors of no follow-up and loss to follow-up. We defined patients who were more than 60 days late for their first follow-up visit as having no follow-up and patients who were more than 60 days late for a subsequent visit as being lost to follow-up. We calculated proportions and cumulative probabilities of patients who had died, stopped ART, had no follow-up, were lost to follow-up, or were retained alive on ART for 36 months. We calculated odds ratios and hazard ratios to examine predictors of no follow-up and loss to follow-up., Findings: Analysis of facility-level data about patients in option B+ who had not transferred to a different facility showed retention in care to be 76·8% (20 475 of 26,658 patients) after 12 months, 70·8% (18,306 of 25,849 patients) after 24 months, and 69·7% (17,787 of 25,535 patients) after 36 months. Patient-level data included 29,145 patients. 14,630 (50·2%) began treatment under option B+. Patients in option B+ had a higher risk of having no follow-up and, for the first 2 years of ART, higher risk of loss to follow-up than did patients who started ART because they had CD4 counts less than 350 cells per μL or WHO clinical stage 3 or 4 disease. Risk of loss to follow-up during the third year was low and similar for patients retained for 2 years. Retention rates did not change as the option B+ programme matured., Interpretation: Our data suggest that pregnant and breastfeeding women who start ART immediately after they are diagnosed with HIV can be retained on ART through the option B+ programme, even after many have stopped breastfeeding. Interventions might be needed to improve retention in the first year on ART in option B+., Funding: Bill & Melinda Gates Foundation, Partnerships for Enhanced Engagement in Research Health, and National Institute of Allergy and Infectious Diseases., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Implementation of user-friendly, real-time, electronic medical records for patient management may lead to improved adherence to clinical guidelines and improved quality of patient care. We detail the systematic, iterative process that implementation partners, Lighthouse clinic and Baobab Health Trust, employed to develop and implement a point-of-care electronic medical records system in an integrated, public clinic in Malawi that serves HIV-infected and tuberculosis (TB) patients., Methods: Baobab Health Trust, the system developers, conducted a series of technical and clinical meetings with Lighthouse and Ministry of Health to determine specifications. Multiple pre-testing sessions assessed patient flow, question clarity, information sequencing, and verified compliance to national guidelines. Final components of the TB/HIV electronic medical records system include: patient demographics; anthropometric measurements; laboratory samples and results; HIV testing; WHO clinical staging; TB diagnosis; family planning; clinical review; and drug dispensing., Results: Our experience suggests that an electronic medical records system can improve patient management, enhance integration of TB/HIV services, and improve provider decision-making. However, despite sufficient funding and motivation, several challenges delayed system launch including: expansion of system components to include of HIV testing and counseling services; changes in the national antiretroviral treatment guidelines that required system revision; and low confidence to use the system among new healthcare workers. To ensure a more robust and agile system that met all stakeholder and user needs, our electronic medical records launch was delayed more than a year. Open communication with stakeholders, careful consideration of ongoing provider input, and a well-functioning, backup, paper-based TB registry helped ensure successful implementation and sustainability of the system. Additional, on-site, technical support provided reassurance and swift problem-solving during the extended launch period., Conclusion: Even when system users are closely involved in the design and development of an electronic medical record system, it is critical to allow sufficient time for software development, solicitation of detailed feedback from both users and stakeholders, and iterative system revisions to successfully transition from paper to point-of-care electronic medical records. For those in low-resource settings, electronic medical records for integrated care is a possible and positive innovation.

Introduction: Sub-optimal performance of healthcare providers in low-income countries is a critical and persistent global problem. The use of electronic health information technology (eHealth) in these settings is creating large-scale opportunities to automate performance measurement and provision of feedback to individual healthcare providers, to support clinical learning and behavior change. An electronic medical record system (EMR) deployed in 66 antiretroviral therapy clinics in Malawi collects data that supervisors use to provide quarterly, clinic-level performance feedback. Understanding barriers to provision of eHealth-based performance feedback for individual healthcare providers in this setting could present a relatively low-cost opportunity to significantly improve the quality of care., Objective: The aims of this study were to identify and describe barriers to using EMR data for individualized audit and feedback for healthcare providers in Malawi and to consider how to design technology to overcome these barriers., Methods: We conducted a qualitative study using interviews, observations, and informant feedback in eight public hospitals in Malawi where an EMR system is used. We interviewed 32 healthcare providers and conducted seven hours of observation of system use., Results: We identified four key barriers to the use of EMR data for clinical performance feedback: provider rotations, disruptions to care processes, user acceptance of eHealth, and performance indicator lifespan. Each of these factors varied across sites and affected the quality of EMR data that could be used for the purpose of generating performance feedback for individual healthcare providers., Conclusion: Using routinely collected eHealth data to generate individualized performance feedback shows potential at large-scale for improving clinical performance in low-resource settings. However, technology used for this purpose must accommodate ongoing changes in barriers to eHealth data use. Understanding the clinical setting as a complex adaptive system (CAS) may enable designers of technology to effectively model change processes to mitigate these barriers., (Copyright © 2015. Published by Elsevier Ireland Ltd.)

Background: There has been little formal analysis of laboratory systems in resource-limited settings, despite widespread consensus around the importance of a strong laboratory infrastructure., Objectives: This study details the informational challenges faced by the laboratory at Kamuzu Central Hospital, a tertiary health facility in Malawi; and proposes ways in which informatics can bolster the efficiency and role of low-resource laboratory systems., Methods: We evaluated previously-collected data on three different aspects of laboratory use. A four-week quality audit of laboratory test orders quantified challenges associated with collecting viable specimens for testing. Data on tests run by the laboratory over a one-year period described the magnitude of the demand for laboratory services. Descriptive information about the laboratory workflow identified informational process breakdowns in the pre-analytical and post-analytical phases and was paired with a 24-hour sample of laboratory data on results reporting., Results: The laboratory conducted 242 242 tests over a 12-month period. The four-week quality audit identified 54% of samples as untestable. Prohibitive paperwork errors were identified in 16% of samples. Laboratory service workflows indicated a potential process breakdown in sample transport and results reporting resulting from the lack of assignment of these tasks to any specific employee cadre. The study of result reporting time showed a mean of almost six hours, with significant variation., Conclusions: This analysis identified challenges in each phase of laboratory testing. Informatics could improve the management of this information by streamlining test ordering and the communication of test orders to the laboratory and results back to the ordering physician., Competing Interests: The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article., (© 2015. The Authors.)

Setting: Chalasa village, Traditional Authority Mtema, Lilongwe District, Malawi., Objectives: To report on the deployment of an electronic register in a rural village with no electricity. Specific objectives were to document 1) challenges in setting up the electronic village register (EVR); 2) demographics of village residents, along with births and deaths over three quarters; and 3) the costs of setting up the system., Design: A descriptive study., Results: The main challenges were slow adoption of the EVR by the village headman, lack of health passports for village residents, double counting of some residents and difficult connectivity. These challenges were overcome. In terms of data, of 790 village residents, 379 (48%) were male, 417 (53%) were aged <15 years and 29 (3.6%) ⩾65 years. From April to December 2013, there were 18 births and 5 deaths. The cost of the EVR, including maintenance costs for 12 months, was US$6210., Conclusion: An EVR was successfully deployed in Chalasa village, rural Malawi, and data on the resident village population, along with quarterly births and deaths, are now available. This is the first step towards a village-level civil registration system in rural Africa.

Cohort analysis has been the cornerstone of tuberculosis (TB) monitoring and evaluation for nearly two decades; these principles have been adapted for patients with the human immunodeficiency virus/acquired immune-deficiency syndrome on antiretroviral treatment and patients with diabetes mellitus and hypertension. We now make the case for using cohort analyses for monitoring pregnant women during antenatal care, up to and including childbirth. We believe that this approach would strengthen the current monitoring and evaluation systems used in antenatal care by providing more precise information at regular time intervals. Accurate real-time data on how many pregnant women are enrolled in antenatal care, their characteristics, the interventions they are receiving and the outcomes for mother and child should provide a solid basis for action to reduce maternal mortality.

Objective: To model the financial effects of implementing a hospital-wide electronic medical record (EMR) system in a tertiary facility in Malawi., Materials and Methods: We evaluated three areas of impact: length of stay, transcription time, and laboratory use. We collected data on expenditures in these categories under the paper-based (pre-EMR) system, and then estimated reductions in each category based on findings from EMR systems in the USA and backed by ambulatory data from low-income settings. We compared these potential savings accrued over a period of 5 years with the costs of implementing the touchscreen point-of-care EMR system at that site., Results: Estimated cost savings in length of stay, transcription time, and laboratory use totaled US$284 395 annually. When compared with the costs of installing and sustaining the EMR system, there is a net financial gain by the third year of operation. Over 5 years the estimated net benefit was US$613 681., Discussion: Despite considering only three categories of savings, this analysis demonstrates the potential financial benefits of EMR systems in low-income settings. The results are robust to higher discount rates, and a net benefit is realized even under more conservative assumptions., Conclusions: This model demonstrates that financial benefits could be realized with an EMR system in a low-income setting. Further studies will examine these and other categories in greater detail, study the financial effects at different levels of organization, and benefit from post-implementation data. This model will be further improved by substituting its assumptions for evidence as we conduct more detailed studies.

Objective: To determine the feasibility of using electronic medical record (EMR) data to provide audit and feedback of antiretroviral therapy (ART) clinical guideline adherence to healthcare workers (HCWs) in Malawi., Materials and Methods: We evaluated recommendations from Malawi's ART guidelines using GuideLine Implementability Appraisal criteria. Recommendations that passed selected criteria were converted into ratio-based performance measures. We queried representative EMR data to determine the feasibility of generating feedback for each performance measure, summed clinical encounters representing each performance measure's denominator, and then measured the distribution of encounter frequency for individual HCWs across nurse and clinical officer groups., Results: We analyzed 423,831 encounters in the EMR data and generated automated feedback for 21 recommendations (12%) from Malawi's ART guidelines. We identified 11 nurse recommendations and eight clinical officer recommendations. Individual nurses and clinical officers had an average of 45 and 59 encounters per month, per recommendation, respectively. Another 37 recommendations (21%) would support audit and feedback if additional routine EMR data are captured and temporal constraints are modeled., Discussion: It appears feasible to implement automated guideline adherence feedback that could potentially improve HCW performance and supervision. Feedback reports may support workplace learning by increasing HCWs' opportunities to reflect on their performance., Conclusion: A moderate number of recommendations from Malawi's ART guidelines can be used to generate automated guideline adherence feedback using existing EMR data. Further study is needed to determine the receptivity of HCWs to peer comparison feedback and barriers to implementation of automated audit and feedback in low-resource settings.

Setting: Antiretroviral treatment (ART) clinics at one central hospital, three district hospitals and one mission hospital in the central and southern regions of Malawi., Objective: To measure the extent of inaccuracies in the transcription of case registration and recorded deaths between electronic medical data (EMR) and paper registers. This was done to inform the Ministry of Health on the reliability of the paper-based system as backup in case of EMR failure., Design: Retrospective analysis of routine programme data., Results: A total of 31 763 registrations and 2922 deaths in the EMR were compared with those in the paper registers. In one hospital, up to 24% of overall case registrations were missing from the paper registers. At other sites, the differences were minor and included duplicate patients who should have been classified as 'transfer in' patients in the paper register. There were major differences in the number of registered deaths in two of the five facilities., Conclusion: There are varying degrees of agreement between the EMR and paper registers which compromise the use of the latter as a backup solution in case of EMR failure. The reasons for this unreliability and ways forward to address the problem are discussed.

The global burden of diabetes mellitus (DM) is immense and predicted to reach 438 million by 2030, with 80% of the cases being in the developing world. The management of chronic non-communicable diseases like DM is poor in most resource-limited settings, and the 'directly observed therapy, short course' (DOTS) framework for tuberculosis control has been proposed as a feasible way to improve this situation. In late 2009, aspects of the DOTS model were applied to the management of persons with DM in the diabetes clinic in Queen Elizabeth Central Hospital, Blantyre, Malawi, and a point-of-care electronic medical record system was set up to support and monitor patients in care. This is the first quarterly and cumulative report of persons with DM registered for care stratified by treatment outcomes, complications and medication history up to 31 December 2010. There were 170 new patients registered between October and December 2010, with 1864 ever registered by 31 December 2010. Most patients were alive and in care; 3 died, 53 defaulted and 3 transferred out. Of those on oral hypoglycaemic agents, metformin was most commonly used. Complications were common. The monitoring and evaluation will be further refined, and at the same time, the systems developed in Blantyre will be expanded to other parts of the country., (© 2011 Blackwell Publishing Ltd.)