Improving care for hypertension and diabetes in india by addition of clinical decision support system and task shifting in the national NCD program: I-TREC model of care

Abstract

Background: The growing burden of hypertension and diabetes is one of the major public health challenges being faced by the health system in India. Clinical Decision Support Systems (CDSS) that assist with tailoring evidencebased management approaches combined with task-shifting from more specialized to less specialized providers may together enhance the impact of a program. We sought to integrate a technology “CDSS” and a strategy “Task-shifting” within the Government of India’s (GoI) Non-Communicable Diseases (NCD) System under the Comprehensive Primary Health Care (CPHC) initiative to enhance the program’s impact to address the growing burden of hypertension and diabetes in India. Methods: We developed a model of care “I-TREC” entirely calibrated for implementation within the current health system across all facility types (Primary Health Centre, Community Health Centre, and District Hospital) in a block in Shaheed Bhagat Singh (SBS) Nagar district of Punjab, India. We undertook an academic-community partnership to incorporate the combination of a CDSS with task-shifting into the GoI CPHC-NCD system, a platform that assists healthcare providers to record patient information for routine NCD care. Academic partners developed clinical algorithms, a revised clinic workfow, and provider training modules with iterative collaboration and consultation with government and technology partners to incorporate CDSS within the existing system. Discussion: The CDSS-enabled GoI CPHC-NCD system provides evidence-based recommendations for hypertension and diabetes; threshold-based prompts to assure referral mechanism across health facilities; integrated patient database, and care coordination through workfow management and dashboard alerts. To enable efcient implementation, modifcations were made in the patient workfow and the fulcrum of the use of technology shifted from physician to nurse. © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Open Access *Correspondence: dr.dev7@gmail.com 1 Centre for Chronic Disease Control, New Delhi, India Full list of author information is available at the end of the article Jindal et al. BMC Health Services Research (2022) 22:688 Page 2 of 12 Background Te growing burden of hypertension and diabetes is one of the major public health challenges being faced by the health system in India [1, 2]. Te Government of India (GoI) initiated the universal annual screening of hypertension and diabetes for all adults’ aged 30 years and older as a component of comprehensive primary health care (CPHC) in 2017 to address the growing burden of Hypertension and Diabetes [3]. From the onset, GoI envisaged using technology to facilitate the screening and management of these conditions. First, Auxiliary Nurse Midwife (ANMs) were to use a mobile app for the identifcation of adults at high-risk for Non-Communicable Diseases (NCDs) like hypertension and diabetes at community level. Second, Medical Ofcers at Primary Health Centres (PHC) were to use a web-based system consisting of an electronic Case Record Form (eCRF) for screening high risk individuals for common chronic conditions and record patient information for routine management and referral. Collectively, this system is called the “GoI CPHC-NCD System.” In addition to longitudinal health record keeping, digital technologies have been successfully used to improve the management of disease. Previous research has shown that the mHealth-based Clinical Decision Support System (CDSS) aided by task-shifting can facilitate guideline-based clinical management of patients and have a signifcant role in bridging these gaps in quality of care [4–6]. However, the development of technology is only a frst step towards widespread adoption of such tools. Te major barriers are the incorporation of technologies as an intrinsic component of the health system across the country and their acceptability by healthcare providers [7]. Many successful evidence informed public health interventions often fail to have an impact beyond the study period or the study population and are not widely adopted due to lack of systematic and efcient uptake by the relevant stakeholders, including governments and health systems in low- and middle- income country settings. Tis exacerbates the “know-do” gap. Trough this study we are trying to understand (a) how best to integrate an evidence-based intervention (i.e. a CDSS) into a national public health program and (b) whether any modifcations are required to incorporate the evidence-based intervention into the national program. Te objective of this paper is to report the integration of an evidence informed digital health intervention with the national public health program for NCD and sharing the learnings that can be useful for other states in India and Low and Middle income countries in southeast Asia and beyond. In this paper, we describe in detail an academic-community-government partnership to incorporate a CDSS within the GoI NCD System and combine this with enhanced provider training and taskshifting strategies. Te resulting model of care is known as I-TREC, or the Integrated- Tracking, Referral, Electronic decision support, and Care coordination platform. Tis experience provides lessons in the adaptations and modifcations made in technologies and health care delivery systems to improve the quality of care for hypertension and diabetes. Methods History Since 2010, the investigators from the I-TREC team (consisting of clinicians, public health specialists, health systems researchers, mHealth technical specialists) has been involved in incremental eforts for developing eCRF and CDSS for a range of conditions operational at varying levels of health care. Te frst CDSS was developed to improve diabetes care at tertiary care settings [8, 9], and this evolved into the development of CDSS for management of hypertension and diabetes at primary and secondary levels of health care [10–14]. In 2017, the state government of Tripura adopted one of the mHealth solutions for improving care for NCDs for the statewide implementation [15]. However, most of this work has been implemented at a single level of the healthcare system (either at primary, or at secondary, or at tertiary care level). We sought to apply the lessons learned at single levels of the healthcare system to develop a “model of care” entirely calibrated for implementation within the current health system, spanning across all levels of care (Primary Health Centre-PHC, Community Health Centre-CHC, and District Hospital-DH), using the core principles of “task-shifting+technology” [16]. Te I-TREC team started the process of developing an integrated model of care for NCDs which can be Conclusion: Designed to be applicable nationwide, the I-TREC model of care is being piloted in a block in the state of Punjab, India. Learnings from I-TREC will provide a roadmap to other public health experts to integrate and adapt their interventions at the national level. Trial registration: CTRI/2020/01/022723