ePOCT+ and the medAL-suite: Development of an electronic clinical decision support algorithm and digital platform for pediatric outpatients in low- and middle-income countries
Authors: Tan Rainer , Cobuccio Ludovico , Beynon Fenella , Levine Gillian , Vaezipour Nina , Luwanda Lameck , Mangu Chacha , Vonlanthen Alan , Santis Olga De , Salim Nahya , Manji Karim , Naburi Helga , Chirande Lulu , Matata Lena , Bulongeleje Method , Moshiro Robert , Miheso Andolo , Arimi Peter , Ndiaye Ousmane , Faye Moctar , Thiongane Aliou , Awasthi Shally , Sharma Kovid , Kumar Gaurav , Van De Maat Josephine , Kulinkina Alexandra , Rwandarwacu Victor , Dusengumuremyi Théophile , Nkuranga John Baptist , Rusingiza Emmanuel , Tuyisenge Lisine , Hartley Mary-Anne , Faivre Vincent , Thabard Julien , Keitel Kristina , D’Acremont Valérie 
Published: September 2022

Electronic clinical decision support algorithms (CDSAs) have been developed to address high childhood mortality and inappropriate antibiotic prescription by helping clinicians adhere to guidelines. Previously identified challenges of CDSAs include its limited scope, usability, and outdated clinical algorithms. To address these challenges we developed ePOCT+, a CDSA for the care of pediatric outpatients in low- and middle-income settings, and the medical algorithm suite (medAL-suite), a software for the creation and execution of CDSAs. Following the principles of digital development, we aim to describe the process and lessons learnt from the development of ePOCT+ and the medAL-suite.

In particular, this work outlines the systematic integrative development process in the design and implementation of these tools required to meet the needs of clinicians to improve uptake and quality of care. We considered the feasibility, acceptability and reliability of clinical signs and symptoms, as well as the diagnostic and prognostic performance of predictors. To assure clinical validity, and appropriateness for the country of implementation the algorithm underwent numerous reviews by clinical experts and health authorities from the implementing countries. The digitalization process involved the creation of medAL-creator, a digital platform which allows clinicians without IT skills to easily create the algorithms, and medAL-reader the mobile health (mHealth) app used by clinicians during the consultation. Extensive feasibility tests were done with feedback from end-users of multiple countries to improve the clinical algorithm and medAL-reader software.

We hope that the development framework used for developing ePOCT+ will help support the development of other CDSAs, and that the open-source medAL-suite will enable others to easily and independently implement them.

AUTHOR SUMMARY

In accordance with the principles of digital development we describe here the process and lessons learnt from the development of ePOCT+, a clinical decision support algorithm (CDSA), and the medAL-suite software, to program and implement CDSAs.

The clinical algorithm was adapted from previous CDSAs in order to address challenges in regards to the limited scope of illnesses and patient population addressed, the ease of use, and limited performance of specific algorithms. Adaptations and improvements to the clinical algorithm was developed based on considerations of what symptoms and signs would be appropriate for primary care level health care workers, and how well these clinical elements are at predicting a particular disease or severe outcome. We hope that by sharing our multi-stakeholder approach to the development of ePOCT+, it can help others in the development of other CDSAs.

The medAL-creator software was developed to allow clinicians without IT programming experience to program the clinical algorithm using a drag-and-drop interface, which we hope allows a wider range of health authorities and implementers to develop and adapt their own CDSA. The medAL-reader application, deploys the algorithm from medAL-creator to end-users following the usual healthcare processes of a consultation.