Sean Broomhead

Chief Technology Officer

  • WHO digital health guideline: 7. Decision support for health workers

    Decision support is the topic of the seventh part of the WHO Guideline on Digital Interventions for Health Systems Strengthening. Key points are summarised below.

    The main WHO recommendation: the use of health worker decision support via mobile devices in the context of tasks that are already defined as within the scope of practice for these health workers.

    Electronic decision support systems help health workers to make better decisions, using available patient data to generate patient-specific assessments or recommendations for the clinician to consider. In many countries, where quality of care is suboptimal, decision support tools can offer guidance to health workers and help to improve adherence to recommended clinical practices.

    Decision support tools can support numerous clinical interactions, including diagnosis, treatment and referrals, to minimize errors and improve care. They use various techniques, including algorithms and rules based on clinical protocols, to create case management checklists and to assist with activity planning and scheduling. Over the last decade, they have progressed to mobile devices, providing unique opportunities for point-of-care assessment, diagnosis and management.

    For community health workers, effectiveness evidence suggests that these tools may have positive effects on their support for patients taking prescribed medication, though may make little or no difference to the clients’ overall health status and their satisfaction with the information they receive.

    Qualitative evidence suggests that health workers find decision support tools useful and reassuring for guiding the delivery of care. However, some health workers perceive algorithms as too prescriptive, and are concerned that they may lose their clinical competencies by blindly following treatment algorithms.

    Health workers are advised to explain to patients that they will use a digital device and seek clients’ permission first, to help ensure that use of the device does not impact negatively on the relationship with the patient.

    While health workers based in peripheral facilities and rural communities may find these interventions particularly helpful, they are also exposed to obstacles such as less access to electricity and network coverage. Challenges related to network connectivity, access to electricity, usability of the device, and sustaining training and support are noted.

    There is extensive additional discussion in the Guideline. Pertinent comments include that the validity of underlying algorithms and decision-logics must be carefully considered and that decision support tools should not be used for tasks that are beyond the health workers’ current scope of practices.

    My next piece in this eHNA series deals with digital tracking of clients’ health status and services.

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    The WHO Guideline provides evidence-based recommendations of ways to use digital health to improve health services. It has a specific focus on mobile devices and emerges out of guidelines on digital health interventions for RMNCAH developed by this team.

    Topics are:

    Evidence is presented under headings of:

    • Effectiveness
    • Acceptability
    • Feasibility
    • Resource use
    • Gender, equity and human rights.

    Implementation considerations address key topics from the WHO/ITU National eHealth strategy toolkit, such as:

    • Legislation, policy and compliance
    • Interoperability and standards
    • Workforce.

    Explore more eHNA coverage of WHO initiatives here.


  • A treasure trove of global goods revealed at DHIS2 2019 conference in Oslo

    Midsummer in Oslo, Norway has become synonymous with the DHIS2 conference, an annual meeting of the global DHIS2 community. This week I have had the pleasure of being part of it, along with 267 other participants from 61 countries and 118 organisation, 17 to 20 June.

    I have seen big changes over the three years I’ve been attending this event. Technology, people and ideas are maturing and aligning to provide a formidable vehicle for positive change, all brought together around the DHIS2, a remarkable global good supporting health strengthening and Universal Health Coverage efforts around the world.

    Hot topics this year include the DHIS2 FHIR adaptor, usability enhancements for a new DHIS2 Android App, extended analytics and visualisation, promising UX/UI enhancements, and many success stories of country DHIS2 use cases.

    I led a team to present on the Human Resource Information System work we have been doing in South Africa. In particular, we showcased an open standards-based interoperability architecture we've developed. It integrates a wide range of primary systems using OpenHIM, HAPI-FHIR, custom NodeJS, IHE mediators and DHIS2 to create a highly responsive, integrated environment. Key products are a Human Resources for Health Registry and a Data Warehouse. They will put data in the hands of various users, including the public, and give decision makers what they need to plan and manage the health workforce.


    A conference highlight is the picnic on Hovedøya Island. Some say that this is where the real work gets done. We will head across this afternoon to swim, barbecue and forge new partnerships for health systems transformation around the world.



    If you are strengthening your country’s health information systems, and haven’t attended a DHIS2 conference yet, then put a placeholder in your calendar for next year.

    I look forward to seeing you in Oslo.

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  • WHO digital health guideline: 6. Targeted client communication for behaviour change

    The sixth part of the WHO Guideline on Digital Interventions for Health Systems Strengthening deals with targeted communication.

    WHO recommends targeted client communication via mobile devices for behaviour change regarding sexual, reproductive, maternal, newborn and child health, under the condition that concerns about sensitive content and data privacy are adequately addressed.

    The idea of sending health messages to help people find care, or to retain them in care, has been around for some time. Digital channels allow progressively more precise targeting of those messages, based on a person’s health status or demographic profile. Channels include text messaging, voice, interactive voice response, multimedia and gamified apps on mobile devices, social media.

    Targeted communication appeared in two previous communicable disease guidelines. The 2016 guidelines on the use of antiretroviral drugs
    include a recommendation on the use of text messaging to support adherence to antiretroviral therapy; and the 2017 guidelines for treatment of drug-susceptible tuberculosis and patient care recommend the use of text messages and voice calls to support health education and treatment adherence.

    Effectiveness evidence evaluated for the Digital Interventions Guideline revealed the following.

    1. There may be positive impacts on some behaviours and health outcomes for:

    • Oral contraception use by adolescents
    • Modern contraception use by adults
    • Adherence to antiretroviral medications
    • Attendance of antenatal care appointments
    • Taking iron and folate tablets during pregnancy
    • Skilled birth attendance
    • Receipt of childhood vaccinations
    • Attendance of HIV appointments among exposed children.

    2. There may be little or no difference to:

    • Health status as assessed by CD4 count
    • Adherence to prenatal antiretroviral medication.

    3. Very low certainty of evidence for:

    • Adherence to antiretroviral medication
    • Attendance for STI/HIV testing among adolescents
    • Breast and cervical cancer screening
    • Women’s attendance for neonatal appointments.

    4. There may be some unintended negative consequences, such as women experiencing physical violence in the context of receiving targeted communications for sexual and reproductive health services.

    Evidence suggests that targeted communication is generally acceptable to individuals, creating feelings of support and connectedness. Nevertheless, some have concerns about the confidentiality of health information, particularly those with HIV infection and other aspects of sexual reproductive health, and may be difficult for people with low literacy, or limited or controlled access to mobile devices.

    There is extensive additional discussion in the Guideline. Pertinent comments include that measures should be taken to address issues such as mobile device access inequities and concerns about sensitive content and data privacy. Attention is also needed to implement adequate consenting procedures, ensuring that clients are aware of how to opt out of receiving the communication. Issues around policy, infrastructure and sociocultural considerations are discussed too.

    My next piece in this eHNA series will summarise recommendations on health worker decision support.

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    The WHO Guideline provides evidence-based recommendations of ways to use digital health to improve health services. It has a specific focus on mobile devices and emerges out of guidelines on digital health interventions for RMNCAH developed by this team.

    Topics are:

    Evidence is presented under headings of:

    • Effectiveness
    • Acceptability
    • Feasibility
    • Resource use
    • Gender, equity and human rights.

    Implementation considerations address key topics from the WHO/ITU National eHealth strategy toolkit, such as:

    • Legislation, policy and compliance
    • Interoperability and standards
    • Workforce.

    Explore more eHNA coverage of WHO initiatives here.


  • WHO digital health guideline: 5. provider-to-provider telemedicine

    Countries need more than warm bodies to staff their health systems, they need those health workers to have appropriate competencies, skills and behaviours. Distance can be a serious barrier to health workers’ interactions. The role of telemedicine in overcoming this is the subject of the fifth recommendation of the WHO guideline on Digital Interventions for Health Systems Strengthening.

    WHO’s review of evidence suggests that provider-to-provider telemedicine “may improve health worker performance, reduce the time for clients to receive appropriate care or follow-up, and decrease length of stay among individuals visiting the emergency department”. It also notes that the opportunity to communicate with one other can help to reduce professional isolation, in particular helping lower-level health workers to access advice to enable better quality of care.

    Nevertheless, evidence also suggests that this form of telemedicine may have little or no effect on health outcomes and some health workers worry about liability and loss of control of their clients’ care.

    WHO recommends provider-to-provider telemedicine in settings where patient safety, privacy, traceability, accountability and security can be monitored.

    Additional comments include a recognition that telemedicine methods are changing with technological advances and that standard operating procedures may help address liability concerns. Implementation considerations include exploring integration with clinical record systems to support provider consultations, reviewing distribution of roles and responsibilities, and considering policy updates to clarify liability issues.

    My next piece in this eHNA series will summarise recommendations on targeted client communication for behavioural change.

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    The WHO Guideline provides evidence-based recommendations of ways to use digital health to improve health services. It has a specific focus on mobile devices and emerges out of guidelines on digital health interventions for RMNCAH developed by this team.


    Topics are:

    Evidence is presented under headings of:

    • Effectiveness
    • Acceptability
    • Feasibility
    • Resource use
    • Gender, equity and human rights.

    Implementation considerations address key topics from the WHO/ITU National eHealth strategy toolkit, such as:

    • Legislation, policy and compliance
    • Interoperability and standards
    • Workforce.

    Explore more eHNA coverage of WHO initiatives here.

  • WHO digital health guideline: 4. client-to-provider telemedicine

    Human resource shortages are a significant obstacle to Universal Health Coverage (UHC) in many countries. Telemedicine, by definition, supports “the provision of health care services at a distance”. The WHO 2010 report Telemedicine Opportunities and Developments in Member States provides a recent update on the factors affecting telemedicine and the WHO guideline builds on this.

    WHO recommends client-to-provider telemedicine:

    • Under the condition that it complements, rather than replaces, face-to-face delivery of health services
    • In settings where patient safety, privacy, traceability, accountability and security can be monitored.

    Effectiveness evidence suggests that telemedicine may improve some outcomes, such as reducing mortality for some conditions, though little or no difference on other outcomes, such as hospital admissions. Qualitative evidence suggests that health workers appreciate being able to offer prompt advice and care, even if physical contact with the patient is not possible, though have concerns about telemedicine reducing client-health worker relationships, leading to poorer care, making health workers work beyond their capabilities, and leading to clinical liability.

    Despite the mix of available evidence, the guideline development group felt that telemedicine has the potential to expand access to health services, though should not detract for health workforce strengthening and needs standard operating procedures to be established. In African countries, where large distances compound health access barriers, telemedicine may be an important part of a national digital health strengthening plan.  

    This is the fourth piece in an eHNA series on the WHO guideline Recommendations on Digital Interventions for Health Systems Strengthening. The previous chapter was about using mobile devices for birth and death notification. The next one deals with provider-to-provider telemedicine.

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    The Guideline provides evidence-based recommendations of ways to use digital health to improve health services. It has a specific focus on mobile devices and emerges out of guidelines on digital health interventions for RMNCAH developed by this team.

    You can find more eHNA coverage of WHO initiatives here.

  • WHO digital health guideline: 3. stock notification and commodity management via mobile devices