Towards an architectural design of a guideline-driven EMR system: a contextual inquiry of Malawi

Computerised clinical practice guidelines are a key component of effective clinical decision support systems, especially in low-resource regions such as Malawi. To address shortages in staffing and budgets for training, the practice of task-shifting, the clinical practice guidelines (CPGs) enable health workers with limited training to provide a standardised level of care. However, CPGs are tradition-ally paper-based, with only a few CPGs having been computerised for Malawi's national electronic health record system. These CPGs have been hard-coded into the system, necessitating significant additional work to add support for future and revised CPGs. We further investigate CPG computerisation challenges in order to understand the motivations for the current computerised CPGs implementation. We use semi-structured interviews, code reviews, and observations in Malawi. Most significantly, we extend existing understanding of software engineering principles to the context of low-resource environments, noting that the tensions between conflicting stakeholder requirements, deadline and deliverable expectations, and good software engineering often result in systems that are harder to maintain, further exacerbating potential problems with longevity of ICTD deployments. We further suggest that a component-based approach in conjunction with communities of open source developers might help alleviate this problem by providing more scalable and robust CPG support.