Design and Development of BACIS Program

The name BACIS combines the names basic antenatal care checklist and information systems. This is to highlight the fact that the BACIS program is an information system that implements the guidelines for maternity care in South Africa and the basic antenatal care checklist process. The BACIS program was conceptualised by the author and the study obstetrician as a tool that could be used at primary healthcare level to improve compliance to maternal health protocols and the BANC checklist. The author's role was that of knowledge engineer and software developer with the study obstetrician acting as the medical domain expert. This chapter presents the technical architecture of the BACIS program. This includes the technology used in creating the system's rule base, as well as the system's data model and software classes and its interface.

Clinical Decision Support Systems

The BACIS program is an example of an e-health decision support system, and therefore a chapter focusing on the topic of decision support systems is needed as part of the background and context to the BACIS program study. The chapter begins with a discussion of the design of decision support systems. In this discussion, the software development methodologies used in their development is explained. Then various architectures for their design are considered. This is followed by a section on implementation of decision support systems in developing country contexts. The chapter closes with a discussion of the Clinical Decision Support (CDS) roadmap of the International Medical Informatics Association.

Design and Development of BACIS Program

In this chapter, the items of system accuracy, usability, and resources implication of adoption of the BACIS program are considered. System accuracy refers to how well the system is able to pick up issues and make alerts. Here, standard items from medical research such as false positives and false negatives are reported. Usability is about how user-friendly the systems are and also how well the system aids the clinician user in his or her work. Resources implications refers to resources that will be needed in implementation of the system. The data for these evaluation items consisted of quantitative data as well as qualitative data. The chapter closes off with a photo essay depicting places and people in South Africa as well as photos from the BACIS program implementation.

The South African Health System

This chapter covers several topics around the theme of primary healthcare. These topics are all foundational and lay the groundwork for the rest of the material in the book. The chapter begins with an overview of the health system in South Africa. This is followed by the topic of the Sustainable Development Goals of the United Nations and their relevance to the work covered in this book, then an overview of the socio-economic characterization of the country. After these follows an overview of the hierarchical organization of health facilities in the country. Then the burden of disease in the country is discussed after it. After the burden of disease follow two sections on interventions aimed at strengthening healthcare services within the country, this is followed by a section on interventions employed broadly in other countries. The chapter ends with the discussion of the topic of the country's e-health strategy and the situating of the work on the BACIS Program within the country's e-health strategy.

Impact of BACIS Program on Quality of Care

The BACIS program was developed then implemented and evaluated. There was an overall improvement in compliance from 85.1% to 89.3% after its introduction. This result was not statistically significant. However, when results were stratified into specific categories, the BACIS program showed statistically significant improvement in compliance over the checklist system in three out of nine important categories. These are compliance at booking, patients younger than 18 years, and patients booking after week 20. Furthermore, a qualitative study was undertaken to understand reasons for non-compliance with the maternal health guidelines. These results, insights, and experiences are valuable to the communities of health, public health, and health informatics persons who are practitioners or researchers in the area of addressing issues of quality in maternal health services.

Implications of System on Health and Public Health Practice and Research

Chapters 10 and 11 were about the methodology and results, respectively, on the system's impact on compliance of the healthcare providers with the maternal health guidelines. Chapter 12 now considers the broader consequences of the BACIS program study. First, a discussion of the results of the BACIS program study in relation to the safe motherhood programme is undertaken. This is followed by a discussion of the issue of non-utilisation of health services, which is an issue that impacts on outcomes and programme success. After this follows a section on the discussion of the results of the BACIS program study against other e-health interventions that are in use or have been proposed, then next against other public health interventions in general, not just e-health systems. The final section discusses the study's results against the backdrop of the broader topic of primary healthcare functioning.

Design and Development of BACIS Program

The work done in the BACIS program study has been divided into two areas of activity: (1) development and piloting of the system and (2) the review of its impact on the quality of care. This chapter addresses the methodology for Activity 1 on design and development of the BACIS program. Activity 1 is based on design science, which is the area in which the design and development of the BACIS program is situated. In the chapter introduction, an overview of design research is given. This is followed by an elaboration of the design science-inspired framework used in the design and development of the BACIS program. The study setting and study participants are also discussed in this chapter on the methodology used in the design and development of the BACIS program.

Way Forward

Chapter 13 addressed a particular future research direction on the issue of porting of the BACIS program onto a pre-existing electronic health record system, the system ported onto being the OpenMRS system. In Chapter 14, other future research directions are considered, which are about topics that need to be considered in taking implementation of the BACIS program forward, as well as other topics that arose from the study. Five future research directions are considered. These are the issue of sustainability of e-health systems implementation, the issue of the CDSS road map, the issue of non-utilisation of health services, the issue of equity in implementation of e-health, and lastly, the issue of use of mathematical modeling in system development.

Dissemination of Clinical Practice Guidelines

After the development of guidelines, methods and strategies for their dissemination need to be formulated. The knowledge base on guideline implementation contains a number of methods that have been employed in guideline implementation and dissemination from around the world. The discussion in this chapter considers the strengths and weaknesses of each of these methods. In the discussion of these methods, a number of factors are considered including the costs of development and implementation of guidelines versus their benefits to patient care. In the summary to the chapter, quantitative improvements in guideline adherence are also noted, as well as a discussion of research around improvements in patient outcomes in addition to the process of care.

Design and Development of BACIS Program

In this chapter, the framework from Chapter 6 on design and development of clinical practice guideline-based decision support systems is used to review the design and development of the BACIS program. The data for carrying out the review of the BACIS program is drawn from three main sources. These are interviews of the health practitioners participating in the BACIS program study, a document review, as well as from observations made by the author during the study in his engagement with study participants during the stages of system development and piloting. In the evaluation, a review of requirements analysis is carried out, as per the framework elaborated in Chapter 6. Then a review of the systems features is also carried out after it.