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 Previously identified challenges of CDSAs include its limited scope, usability, and outdated clinical algorithms.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.

The authors have declared no competing interest.

This work took place within the framework of the DYNAMIC project that is funded by the Fondation Botnar, Switzerland (grant n 6278) as well as the Swiss Development Cooperation (grant n 7F-10361.01.01) received by VDA. The TIMCI project funded by UNITAID (grant n 2019-35-TIMCI) received by VDA allowed for adapting of ePOCT+ or the medAL-suite software to Senegal, Kenya and India. The funders had no role in the development of ePOCT+ or the medAL-suite software, data collection, analysis, nor did they have a role in the decision to publish, or preparation of this manuscript.

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Ethics committee/IRB of Ifakara Health Institute in Tanzania, the National Institute for Medical Research in Tanzania, the National Ethics Committee of Rwanda, the Comite National d Ethique pour la Recherche en Sante of Senegal, the University of Nairobi Ethics and Research Committee in Kenya, the King George s Medical College Institutional Ethics Committee in India, the Indian Council of Medical Research, the cantonal ethics review board of Vaud, Switzerland, and the WHO Ethics Review Committee, the Ethikkommission Beider Basel in Switzerland, and the Boston Children s Hospital, all gave ethical approval for this work

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