Development, implementation, and usability evaluation of an mHealth-based clinical decision-support system for strengthening antimicrobial stewardship among physicians in Pakistan: A mixed-methods study

Objective: Antibiotic resistance is a major global health threat, driven by inappropriate antimicrobial prescribing. Mobile health (mHealth)-based clinical decision-support systems (CDSS) may strengthen antibiotic stewardship, but evidence from resource-limited settings remains limited. This study reports the development and implementation of ComBact, an mHealth-based CDSS for seven infectious disease syndromes, examines physicians' perceptions of its clinical utility, and evaluates system-level usability metrics at a private tertiary-care hospital in Pakistan. Methods: A convergent parallel mixed-methods design was used. Semi-structured focus group discussions (FGDs) were conducted with internal medicine physicians who had access to ComBact for one year. Transcripts were analyzed using Braun and Clarke's thematic framework. Quantitative analysis included system-generated data on user registration, uptake, and detailed usage metrics. Findings from both components were integrated using a joint display. Results: 61 clinicians registered for ComBact, all accessing the dashboard at least once. The app recorded 134 sessions, with a mean of 1.23 pathway revisits per session and a mean workflow duration of 1 minute 25 seconds; 32.7% of users completed a ComBact plan. Mobile phones accounted for 57.4% of access and desktops for 42.6%. Two FGDs were conducted with fifteen physicians (median age 31 years (IQR: 27-34 yr). Five themes emerged: (1) clinical applicability, (2) user experience, (3) need of the app, (4) content limitations, and (5) recommendations. Conclusions: ComBact was perceived as a user-friendly tool with meaningful potential to support antimicrobial stewardship in LMICs, though significant content and functional enhancements are needed.