CITATION: Haddad SM, Souza RT, Cecatti JG, Barreix M, Tamrat T, Footitt C, Mehl GL, Syah IF, Shankar AH, Tunçalp Ö
Building a Digital Tool for the Adoption of the World Health Organization’s Antenatal Care Recommendations: Methodological Intersection of Evidence, Clinical Logic, and Digital Technology
J Med Internet Res 2020;22(10):e16355
DOI: 10.2196/16355
PMID: 33001032

ABSTRACT
Background: One of the key mandates of the World Health Organization (WHO) is to develop guidelines, defined as “a document containing recommendations for clinical practice or public health policy.” Guidelines represent the global standard for information sources shaping clinical practice and public health policies. Despite the rigorous development process and the value of guidelines for setting standards, implementing such standards within local contexts and at the point of care is a well-documented challenge. Digital technologies enable agile information management and may facilitate the adaptation of guidelines to diverse settings of health services delivery.

Objective: The objective of this paper is to detail the systematic and iterative process involved in transforming the WHO Antenatal Care (ANC) guidelines into a digital decision-support and patient-record application for routine use in primary health care settings, known as the WHO digital ANC module.

Methods: The WHO convened a team of clinical and digital health experts to develop the WHO digital ANC module as a tool to assist health care professionals in the implementation of WHO evidence-based recommendations for pregnant women. The WHO digital ANC module’s creation included the following steps: defining a minimum viable product (MVP), developing clinical workflows and algorithms, algorithm testing, developing a data dictionary, and the creation of a user interface or application development. The overall process of development took approximately 1 year to reach a stable prototype and to finalize the underlying content requirements of the data dictionary and decision support algorithms.

Results: The first output is a reference software reflecting the generic WHO ANC guideline content, known as the WHO digital ANC module. Within it, all actionable ANC recommendations have related data fields and algorithms to confirm whether the associated task was performed. WHO recommendations that are not carried out by the health care worker are saved as pending tasks on a woman’s health record, and those that are adequately fulfilled trigger messages with positive reinforcement. The second output consists of the structured documentation of the different components which contributed to the development of the WHO digital ANC module, such as the data dictionary and clinical decision support workflows.

Conclusions: This is a novel approach to facilitate the adoption and adaptation of recommendations through digital systems at the health service delivery level. It is expected that the WHO digital ANC module will support the implementation of evidence-based practices and provide information for monitoring and surveillance; however, further evidence is needed to understand how the WHO digital ANC module impacts the implementation of WHO recommendations. Further, the module’s implementation will inform the WHO’s ongoing efforts to create a pathway to adaptive and integrated (Smart) Guidelines in Digital Systems to improve health system quality, coverage, and accountability.

COMMENT (NPW): As the authors say in the full text, ‘Ultimately, prescriptive and rigid recommendations are not appropriate or optimal, and over time, the WHO has moved toward context-specific recommendations and has developed tools that allow for the design of health care services based on local settings. However, at the same time, doing so has also changed the complexity of interpreting and implementing recommendations. Digital tools have the potential to facilitate and accelerate the implementation of such guidelines on the ground.’ This contextualisation is crucial. The authors note: ‘Despite the rigorous development process and the value of guidelines for setting standards, implementing such standards within local contexts and at the point of care is a well-documented challenge.’ Importantly, their tool is ‘customizable to diverse country contexts’.

Best wishes, Neil

Coordinator, HIFA Project on Evidence-Informed Policy and Practice
http://www.hifa.org/projects/evidence-informed-policy-and-practice