• Standards
  • Kenya’s mHealth standards for documentation add clarity

    Covering a wide range of mHealth standards, Kenya’s Ministry of Health has set a firm foundation to step up its wide eHealth regulation and good practices. The first main section in Kenya Standards and Guidelines for mHealth Systems deals with development and functions. It’s comprehensive.

    Software development has to comply with a set of phases: 

    Requirement gatheringSystems analysisSystems designDevelopment and implementationSystems testingOperations and maintenanceSupportPost-implementation M&E.

    Documentation needed for these includes:

    ·       Systems Requirement Specification (SRS)

    ·       Software design documents, depending on the mHealth software design methodology, will include some of:

    o   Unified Modelling Language (UML) diagrams

    o   Data Flow Diagrams (DFD)

    o   Flow charts

    o   Entity relationship diagrams

    ·       Implementation plan, including:

    o   Implementation manual

    o   Training and capacity building manual

    ·       Test plans

    ·       Deployment procedures

    ·       M&E criteria.

    Three other required documents are:

    Technical manualDeveloper’s guideUser manual.

    Four requirements for data validation are included:

    First order, ensure valid data formats and values and prevent obvious data entry errorsSecond order, historical data comparisons for alerts for changesThird order assess data for consistency in specific forms and indicator setsFourth order, assess statistical outliers for validity. 

    These examples show the range and rigour of Kenya’s mHealth standards. They fit all types of eHealth too. It’s a considerable benchmark for all Africa’s health systems.

  • US eHealth IOp should focus on big impacts

    Interoperability (IOp) in eHealth isn’t an absolute state. Measuring it isn’t either. Sir William Osler, a Canadian doctor and one of four founding professors of Johns Hopkins Hospital, didn’t need to bother with eHealth IOp, but hinted at it in strategy when he said “In seeking absolute truth we aim at the unattainable and must be content with broken portions.”

    Challenges are how much, and which IOp measurement will achieve contentment without breaking it. An article in Fierce Health provide some indication. It sets out responses from five US organisations to the Office of the National Coordinator (ONC) report in the Proposed Interoperability Standards Measurement Framework, reported by eHNA in May.

    It has two main themes.  One’s measuring standards implementation. The other’s how end users can refine and customise standards to meet their needs. Most groups expressed some trepidation that new standards would result in an undue burden for providers. They want the ONC to focus on measurement areas with the biggest impact. Their advice is directly relevant for Africa’s IOp plans.

    The American Medical Informatics Association (AIMIA) supported the ONC’s framework in its response. It also asked the ONC to target “high-value standards” that offer the biggest impact. Specific requirements are functionalities for accessing drug databases and transmitting laboratory data. It wants the measurement framework to be automated too, so easier reporting mechanisms translate to higher participation.

    A combination of support and caution was part of the Health Information Management and Systems Society (HIMSS) contribution. It offers three main themes: 

    Limiting undue burden by leveraging the use of existing reporting frameworksStandards as the means, with the standards measured aligned to use cases critical to advancing IOp and better information exchangeIncluding all relevant stakeholders, including the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC).

    A sub group of HIMSS, the Electronic Health Record Association (EHRA) suggested a combination of standardised approaches with non-standard methods. It’s a focus on use cases with the biggest impact. It emphasised the potential burdens too.

    The College for Health Information Management Executives (CHIME) highlighted patient matching as one of the biggest IOp barriers. It says measurement standards are premature, and wants the ONC to:

    Develop standards for seamless communication between ICT systemsEnsure that data exchange identifies patients with 100% certaintyMake data exchange usable for clinicians before tackling IOp standards.

    CHIME proposed that if the measurement framework’s implemented, the ONC should work with stakeholders to prioritise cases and develop a granular set of standards.

    Health IT Now, a coalition of patient groups, healthcare organisations, employers and payers, recognises that measuring IOP’s necessary, and said a narrow focus on successful data transmissions devalue improvements in using data to improve care and defer the capability of health systems to exchange information. It wants collaboration with patients and patient advocates and private sector organisations that can contribute to identifying, developing, and deploying IOp standards for better information systems.

    These perspectives can inform Africa’s eHealth development. IOp and its choices are seldom off the eHealth agenda.

  • Kenya’s setting up new mHealth legislation

    Africa’s eHealth legislation and regulation needs considerable developed. Kenya’s stepping it up, eHealth experts have welcomed proposed eHealth legislation, including the Health Act 2017 and the Kenya Standard and Guidelines for mHealth Systems. They see the legislation as facilitating Interoperability (IOp) between private and public healthcare, and as guidelines to move wider eHealth on says an article in ITWEB Africa.

    The Health Act 2017 says within three years of its operation, the Ministry of Health (MoH) will implement management information banks. They’ll include an IOp framework for data interchange and security to improve personal health information management.

    Tony Wood, Managing Director at My Dawa, an online service for ordering prescription and wellness products, said he welcomed legislation that builds the eHealth ecosystem. "With everything, as you look at the world, technology is moving faster than regulation, governments and policy. More can now be done on how these are implemented going forward. I hope they are going to be implemented through open consultation where the public and private sector are working together." This seems like the next step.

    The 66-page guidelines are wide ranging. They set out definitions and extend across mHealth implantation, standards, governance and policy. The proposed legislation’s scheduled for debate in the national assembly. It’s a crucial stepping stone implementing successful and sustainable mHealth and wider eHealth.

  • Now's your chance to be certified in SNOMED CT

    Terminology standards are part of health informatics’ core. Opportunities in Africa to acquire the skills are limited, both in access to universities and affordability. Now, there’s a chance to use eLearning to gain a certificate in the health terminology standard Systematized Nomenclature of Medicine--Clinical Terms, commonly known as SNOMED CT.

    IHTSDO, SNOMED CT’s owner, has recently launched their eLearning platform. It provides online courses, tutorials and other materials designed to enable you to learn more about SNOMED CT. They also offer completion certificates to people who pass course assessments. 

    At this stage, courses available are the SNOMED CT Foundation course and SNOMED CT Implementation modules. The foundation course is self-paced. You can start shortly after you register. Both courses are free, and provide a valuable opportunity for health informatics students and leaders to learn and share knowledge about an important eHealth building block.

    To find out more about these education services please visit the E-Learning Overview. For access to courses, tutorials and other educational materials go to the SNOMED CT E-Learning Server. If you have any questions, or want more specific information about the opportunity and how you make the most of it, you can email IHTSDO at info@ihtsdo.org.

    This’s a big opportunity for Africa’s eHealth. If you’re taking it up, please let eHNA know about your experiences so you can share it.

  • IHE, AHIMA and HIMSS promote better eHealth standards

    Integrated Health Enterprise (EHI) with the American Health Information Management Association (AHIMA) and the Healthcare Information and Management Systems Society (HIMSS) have released a robust and thorough white paper on health ICT and information infrastructure, security and Interoperability (IOp). It includes eight capabilities needed for information protection:

    Ensure appropriate levels of protection from breach, corruption and loss of private and confidential information classified and essential to business continuity or other reasons Consistently apply and enforce levels of protection to information from the moment it’s created until the moment it reaches or exceeds its retention period and is appropriately disposed, including adherence to security, privacy and confidentiality rules, regulations and policies when determining a method for the final disposition of information, regardless of source or media, and whether the disposition is archival, transfer to another organisation, preservation for permanent storage or destruction Establish an audit programme that defines a clear process for verifying whether sensitive secure information is being handled in accordance with organisations’ policies and procedures Manage and balance compliance with the varying degrees of protection, mandated by laws, regulations, and organisations’ information policies Provide security, business continuity, and disaster recovery processes that ensure continued operation and protection during and after periods of failure or disruption Assign and manage appropriate levels of information access and security clearance to all members of the workforce and other authorised parties relevant to their roles or duties Maintain appropriate security safeguards, clearly defined and enforced by organisations’ policies that protect electronic information from being inappropriately viewed, emailed, downloaded, uploaded or proliferated intentionally or inadvertently Provide physical security safeguards for computing and access devices and equipment containing organisations’ private, secret or confidential information or intellectual property.

    It identifies numerous gaps in both Health Information Management (HIM) practices and standards development. Fixing these needs compliance with recommendations for HIM professionals and Standards Development Organisations (SDO):

    Standardise and harmonise the scope and operations of organisations’ information committees in line with the information governance principles Harmonise and standardise Committees’ policies across healthcare organisations Develop a template of organizational policy related to documentation development and management Define a standardised set of documentation for episodes of care Collect applicable documents that are available for complete episodes of care Define policies on open and closed records and the processes and timeliness of record completion, including finalising definitions on open records such as incomplete, lost, delinquent and cancelled Define policy that outlines how clinicians are notified of open and closed records when: Procedures are ordered but not performed Documentation components are missing or signatures are missing Define a minimum set of content to be analysed for timeliness and completeness of legal records Define data provenance of content and source for metadata tags such as the who, what, when, where, why Designate HIM representatives to participate at HL7 Working Groups including: HL7 Community-based Collaborative Care (CBCC) Work Group Review the Patient Friendly Consent Directive standard ballot.

    While information security is close to an absolute state, IOp isn’t, The big IOp challenge for Africa’s eHealth’s how much IOp’s enough?

  • Accrediting suppliers for procurement isn't enough

    An important part of eHealth regulation’s accrediting suppliers. An aim’s to be sure that functionalities and standards in supplier’s solutions match health system’s information requirements. It’s a good idea to match the two perspectives before procurement. It also avoids wasting time where bidders don’t comply, but it’s not enough.

    A USA Senator, Dr Bill Cassidy and Sheldon Whitehouse, don’t think accreditation’s good enough. Whitehouse has said ”After a health IT product is certified for use, there’s no way to ensure that it continues to deliver as promised for doctors and patients, and no way to easily compare one product to another,” so, they’re proposing legislation, the Trust Act, to improve it. These are important developments for Africa’s eHealth regulation and procurement.

    It aims to make health IT suppliers accountable for their systems’ performances in:

    Security Usability Interoperability (IOp).

    It’ll achieve this by establishing a Health IT Rating System so consumers can compare certified health IT products on the three criteria. The bill also establishes a process to collect and verify confidential feedback from healthcare providers, patients, and other users on usability, security and IOP.

    Other measures include:

    Making information, such as summaries, screen shots, or video demonstrations, showing how certified health information technology meets certification requirements publicly available Requiring the certification programme establish that health IT products meet applicable security requirements, incorporate user-centred design, and achieve IOP consistent with the reporting criteria used in the Health IT Rating Programme Requiring health IT vendors to attest that they don’t engage in specified information blocking, such as nondisclosure clauses in their contracts, as a condition of certification and maintenance of certification Authorises ways to investigate claims of information blocking and assess civil monetary penalties on anyone, or entity, found to have committed information blocking.

    These enhanced requirements should enable health ministries and other users to track the performance of their health IT providers beyond the procurement stage and into routine operation. It’s an important activity for Africa’s health systems and can step up their market power in regulation and procurement.

  • SNOMED CT benefits Kenya's healthcare

    Sub-Saharan Africa (SSA) experiences various challenges in delivering healthcare. While some of the challenges such as privacy and security concerns are encountered in developing and developed countries, others, such as overworked and often poorly trained health workers, inadequate computer resources, and unreliable electric power and Internet access, are unique to developing countries. As SSA countries continue to invest in EHRs to improve the quality of patient care, these challenges have to be overcome to maximise benefits.

    Transferring patient records between health facilities electronically or accessing records on a shared database is often a challenge. Clinicians who previously saw patients prepare treatment histories may use terms and parameters local to their health facility. These may not have the same meaning at other facilities. For example, the temperature range used to describe a fever at one clinic may be different from the range in another.

    Lack of standard definitions of clinical terms such as diagnoses, observations, signs and symptoms can compromise the continuity and quality of care when patients are seen by different clinicians during different hospital visits. Clinicians often use different terms to refer to the same thing; for example one clinician may record a diagnosis as “shingles” and a different clinician records the same diagnosis as “herpes zoster”. The two terms refer to the same diagnosis.

    In HIV care, the recorded diagnosis, signs and symptoms during a patient visit to a clinic is often used as part of the decision support process to determine whether or not the patient is eligible for anti-retroviral therapy (ART). The World Health Organization (WHO) classifies HIV-related opportunistic infections into four clinical stages that are indicative of HIV disease progression. This helps clinicians in resource-limited settings with no immediate access to an advanced laboratory to make decisions on ART eligibility. It needs accurate, unambiguous diagnoses and correct recordings of results as these determine whether to prescribe ART or not. Wrong, ambiguous diagnoses or incorrect recordings could result in under-treatment or over-treatment. The effects are serious, possibly leading to drug-resistance or in some cases, even death.

    To address these challenges, there’s a need for a standardised system for coding and recording terms used in clinics to ensure consistency. SNOMED CT is one of the most comprehensive and precise clinical health terminology products in the world and can be used to standardise terminology of clinical recording. The Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) in Kisumu County, western Kenya, recognised the challenges in continuity of care and the need for standardised recording of data for decisions on ART eligibility for more than 7,000 HIV patients enrolled at the facility. They developed a concept dictionary; a collection of common terms used to describe procedures, diagnoses and signs and symptoms associated with HIV infection. Each term’s linked to a SNOMED CT ID, a unique identifier that ensures terms have consistent meanings across the hospital. The concept dictionary is part of the EHR, which is built on an OpenMRS platform to manage patients’ health records at JOOTRH and at several other clinics in Kenya. Many developing countries use this model too.

    Since SNOMED CT also contains alternative terms, its synonyms, for many concepts, clinical users have options of using a preferred term or a synonym. All these options are displayed on the EHR’s data entry screen. It provides a flexible and accurate way to record information so clinicians can use local terms that their colleagues are most familiar with. The local concept dictionary can be updated whenever new parameters are defined that are not already stored. If a clinical expression does not exist in SNOMED CT, users can create it using a pre-coordination or post-coordination process.

    Although there has been a significant improvement of completeness of patient records since introducing SNOMED CT’s concept dictionary, a formal evaluation is planned to assess the effect of its use as a terminology system on data and healthcare quality by using accurate recordings of diagnoses and automated inferences of ART eligibility for HIV patients in a resource-limited setting. This should set the direction for the SNOMED CT’s use across Africa’s healthcare.

  • Why are eHealth strategies hard to implement? Lesson 4

    In his book On War, Carl von Clausewitz, the 19th century military strategist said “Everything in strategy is very simple, but that does not mean that everything is very easy…. But great strength of character, as well as great lucidity and firmness of mind, is required in order to follow through steadily, to carry out the plan, and not to be thrown off course by thousands of diversions.”

    eHealth’s similar. Its strategies set out directions for investment in development such as new health ICT systems, architecture, interoperability, standards, resources and benefits. Converting them into action seems to prove more demanding than strategies envisage. African countries are not alone in this quest, so what are the lessons?

    First, many eHealth strategies have many initiatives that fit into a relatively short time scale of some three to five years. There are two inbuilt constraints. One is that there’s often too many. The other is that some of the initiatives have much longer timescales. An example is the USA’s national interoperability road map. It has a ten year timescale, as posted on eHNA. It seems realistic, so can’t fit into a strategy with a horizon of five years or less. The lesson is, either extend your strategies timescale, or shrink the initiatives to fit.

    Implementation needs different skills to strategies. Guru’s often invoke leadership components. Examples are:

    Three Cs of Implementing Strategy by Scott Edinger in Forbes, who says it needs you to clarify, communicate and cascade your strategy Managing Performance Execution & Implementation Process By Shannon Sage in On Strategy, who says: 90% of organisations fail to implement their strategies 60% link strategy to budgeting 75% don’t link employee incentives to strategy 86% send less than one hour per month discussing strategy 95% of a typical workforce doesn’t understand their organization’s strategy.

    She proposes a leaders’ self-assessment test:

    How committed are you to implementing your strategy? How do you plan to communicate it? Are there sufficient people with buy-in to drive it on? How are you going to motivate your people? Have you identified the internal processes you need to drive it forward? Are you going to commit money, resources, and time to support it? What are the roadblocks to implementation and support? How will you take available resources and achieve maximum results?

    With implementation skills different to strategic skills, you have to have to right human capacity and capabilities in place. These include health workers who can release time for engagement, project management broads, project managers, informatics teams, ICT support teams, procurement teams, trainers and training time, devolved budgets, accountability links, a devolvement plan for corrective decisions.

    The scale and scope of these will determine progress. As these are scarce resources, scale and scope is likely to be limited. An assessment of these can as part of formulating an eHealth strategy help to integrate implementation and strategy and ensure realism for both. One way to do this is to have an eHealth strategy that sets out the initiatives needed, but without a timescale. It then becomes the source of actions for selection to transfer into a rolling three to five-year plan. This is appropriate for countries with constrained resources, so can fit Africa’s healthcare.

    Perhaps the most demanding part of implementation is securing the changes to clinical and working practices and healthcare transformations needed for success. An example is eHNA’s post on EHRs need new healthcare models. It shows that eHealth is much more than health ICT. Implementing eHealth is much harder than implementing ICT systems. Realising eHealth’s benefits must be part of implementation. Clausewitz view on this is that “The relations between material factors are all very simple, what is more difficult to grasp are the intellectual factors involved.” This is why implementation is so challenging, and not just for African countries.

  • Why is Health IT not only about IT and how SNOMED CT helps?

    Healthcare is a knowledge industry, and information is one of its core commodities and one of its enablers. The purpose of an electronic health record (EHR) system is twofold.  First, EHRs place accurate and complete information in the hands of clinicians when and where they can best support quality patient care.  Second, they enable meaningful sharing and use of health information throughout the healthcare system. Systems that meet these objectives offer better outcomes for patients, populations and the healthcare system as a whole.

    Keys to a successful EHR

    Accenture, in 2015, said the global EHR market is expected to exceed US$22 billion, largely as a result of government 
incentives and mandates. This expenditure of public funds is an investment in systems which, in many countries, is expected to improve quality, safety and efficiency of their healthcare systems, and help stem a tide of rising costs instigated by the demands of aging populations, increased prevalence of chronic diseases, rising consumer expectations and advances in the life sciences.

    Beyond initial reductions in record keeping and storage costs, benefits from EHR implementation will most likely realized in proportion to an EHR’s ability to share and use clinical information to enable or enhance patient, population or health system outcomes. To help support adoption and effective use of clinical information systems, HIMSS Analytics and Gartner have produced well-established assessment tools which identify key features and capabilities of clinical systems at different levels of maturity and use. Both identify structured data and controlled medical vocabularies, such as SNOMED CT, and described on its page. It’s an essential EHR feature needed for advanced interoperability to enable widespread sharing and use of clinical information.

    Data that makes sense

    Simply put, computers, like people, can process and act on information better when its presented in a familiar format using familiar language. Formally structured information and controlled vocabularies, like SNOMED CT, enable EHRs to recognize important information in patient EHRs and to use it to support healthcare decision making, care delivery, monitoring, reporting and analysis.

    Some clinical information systems use integrated terminology products to help automate administrative coding, capture processes, and employ standards-based data exchange to link local systems to government-hosted knowledge resources. These interconnected solutions are important because stakeholders throughout the healthcare community have interdependent and shared information needs. For example:

    Healthcare providers, regulators, public and private sector payers and researchers all use information gathered at points of care to provide services that help make healthcare accessible, safe and effective for patients Healthcare providers aware of innovations, regulatory requirements and patients’ healthcare coverage are better at personalized healthcare that includes developing care plans aligned with best practice and tuned to patient needs and ensuring patient compliance and patient outcomes.

    Why standards?

    A combination of different standards in a healthcare system provides a clinically validated way for computer systems to collect, connect, aggregate, translate and exchange health information for various uses. An EHR without standardized, structured data is just a computer with only a paper record functionality.

    Information systems that can recognize patterns in health information and deliver current and actionable information to healthcare providers that’s relevant to their work, can help users stay abreast of innovations, recognize patients’ needs and deliver better outcomes for their patients.

    Long term investment

    From an economic perspective, health information has potential to deliver economic and socio-economic returns to organizations. Return to organizations as cost savings accrue from uses that improve patient outcomes or provide more effective and efficient use of technology and pharmaceuticals. Socio-economic returns include benefits to patients, carers, communities, healthcare providers, payers, population health management and researchers.  Many of these accrue from better informed patients, safer healthcare, more streamlined healthcare, better productivity and less waste Several studies show that the cost for standards implementation is minor in relations to the return in a longer perspective.

    Health information in unstructured narrative form is difficult and expensive to exchange and reuse. An example is the significant time lag between knowledge discovery and its translation into everyday practice. Consistently, encoding information in EHRs, clinical criteria within decision support tools, and abstracts of knowledge resources using SNOMED CT, helps make health information more discoverable, more exchangeable, and more interoperable, and more reusable across organizations. The benefit is more efficient and effective healthcare services as information is shared, leading to improved patient and population health, better and more appropriate use of technology, improved health system financial outcomes and societal benefits that accrue from a healthy populations and more efficient and effective use of healthcare resources.

    The big challenge is that decisions are needed on which standards to use to enable optimal interoperability. It’s compounded when vendors use different ones that suit their product best. The “e” in eHealth or the “IT” in health IT can help to achieve better health as long as it reflects all aspects, such as people, organization, standards for technical and semantic interoperability, and not to leave out the patients and their carers.

  • WHO defers ICD-11 until 2017

    The World Health Organization’s (WHO) International Classification of Diseases (ICD) is a global standard for information about mortality and morbidity. Over 100 countries use it to report mortality data; more than half the countries in the world. WHO has now set 2017 as the year to release ICD version 11; a three-year development phase.

    Modern ICT will enable public health users input data online into ICD-11’s beta version of ICD-11 using an online revision process. WHO is keen for a broad adoption of ICD-11 so that health information becomes more comprehensive than data from ICD-10 and its Clinical Modifications (CM). The USA has not yet implemented ICD-10 fully, so another potential change is looming in a few years. ICD-10 has been around with various CMs since 1993.

    FierceHealthIT  has reviewed ICD-11’ history and says that WHO’s timetable for ICD-11 has slipped from its initial availability in 2012; a five-year delay. It may take countries a few years after 2017 to adopt ICD-11 and use it fully.

    African countries can include their approach to ICD-11 in their medium term eHealth strategies and plans. It needs strategies and plans to manage a switch of ICDs. In the Journal of Health Information in Developing Countries, Sulaiman Bah, a Faculty Member of University of Dammam’s College of Applied Medical Sciences in Saudi Arabia,  reviewed the switch from ICD-9 to ICD-10  in South Africa and identifies strategies for change.

    When finalized, ICD-11 will be ready to use with electronic health records and information systems.

    WHO encourages broad participation in the 11th revision so that the final classification meets the needs of health information users and is more comprehensive.