• Strategy
  • 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.

  • Botswana's cyber-security strategy's in the pipeline

    The UK government, through the Commonwealth Telecommunications Organisation (CTO), has pledged to help Botswana develop its National Cyber security Strategy. ITWEB Africa says the strategy is expected to establish a national cyber-security policy framework, develop and harmonise appropriate legislation to address cyber-security challenges, create capacity building and public awareness on cyber security issues, and establish a National Computer Emergency Response Team (CERT).

    Botswana's Minister of Transport and Communications, Tshenolo Mabeo said "It is very important that we jealously guard the safety, security and resilience of the cyberspace, so that we can enjoy its socio-economic benefits." He added that the evolution and use of the cyber-space on shared principles, norms and procedures as an open access system is one of the greatest innovations that mankind has ever experienced but warns that it needs protecting and guarding from cybercriminals.

    The framework aims to help to guard healthcare data, which is vulnerable to cyber-attacks. The next step after the framework is to develop and apply effective cyber-security measures. 

  • More mHealth lessons for Africa? Lessons learned 3

    mHealth is offered as an important component of African countries’ eHealth strategies. As investment grows, it’s important to incorporate the lessons learnt, both good and bad.

    There’s no doubt that mHealth and its apps can reach many people and communities who need healthcare and opportunities to improve their health. Both SMS and apps can have a positive role that supplements Africa’s heavily constrained health workforce. It leads to the most important lesson of using mHealth to focus on people, communities and specific health needs. The opportunities are expanding daily.

    Where this results in a series of apps for each disease or condition, the challenge then is to combine the data into individuals’ medical records. Where these are EHRs, architecture and interoperability are essential components of mHealth initiatives. Dealing with them needs dedicated resources as mHealth initiatives expand.

    For effective mHealth, the Journal of the American Medical Association (JAMA) has highlighted concerns that safety of mHealth apps is unknown. This leads on to a conclusion that many apps could be problematic for users and caregivers. Alongside this, there may be cyber-security and regulatory concerns. These lead to questions for mHealth projects, such as, is the service safe, beneficial, compliant with regulations and secure?

    Other regulatory features of mHealth that need setting in place include:

    • Who’s data is it?
    • How does it link to other eHealth data?
    • How is the data used for secondary purposes, such as population health management?
    • How is maintenance and obsolescence dealt with?
    • How does mHealth link securely to the Internet of Things (IoT)?

    Acfee maintains a regulatory model of 64 regulatory aspects and a roadmap for closing gaps, which may help African countries move forward.

    Another lesson is to ensure that mHealth initiatives are evaluated rigorously before and after implementation. Findings from mHealth that’s already operational provide insights and knowledge for future assessments and investment decisions.

    These findings are valuable for decisions on scaling-up mHealth. It’s a common challenge. With very scarce resources, scaling-up an mHealth initiative denies resources for a new mHealth initiative. Choosing between them is not easy. A middle way offers the opportunity to expand and keep innovating. African countries can have a mHealth strategy that allocates resources and finance for scaling-up and new ideas. A medium-term financial plan can help plan the way ahead.

    mHealth is still in its infancy across Africa. In addition to individual projects, it’s important that health ministries set a longer-term context where mHealth in Africa is widespread, integrated and keeps expanding.  It can help to set a scenario where mHealth app developers can see how they fit their ideas and imagination into health and healthcare priorities and opportunities. It can help to stimulate the flow of sustainable new apps too.

  • What difference will eHealth make in SA over the next ten years?

    In the film Terminator, the central character sent back from 2029 didn’t need much healthcare, but was packed with technology and the ability to change, two of the top requirements for successful eHealth. The current crop of eHealth initiatives needs to deliver more if they’re to have a big impact over the next ten years. It also needs supplementing with more innovative opportunities, such as health analytics, Big Data and the expanding Internet of Things (IoT). Many African countries are well along this journey and are changing the way they absorb eHealth as a core resource. In South Africa, the Government’s plans to establish a ministerial advisory committee on eHealth show foresight likely to step up the importance of eHealth and to move things in the right direction. Draft regulations are out for comment.

    There are numerous claims that eHealth can transform our health and our healthcare systems and provide the means to cope with the increasing demands of an ageing population. If the claims are false, then they just increase the heap of fictional, hyperbolic and fanciful panaceas. If they’re true, immense changes are needed, and “change always brings strong opposition”. As many African countries look to South Africa to take an eHealth lead, internal leadership is always a key lever and has to extend across political, executive and clinical domains. This eHealth leadership isn’t quite the same as leadership in conventional entities where groups of stakeholders are less numerous.

    Considerable attention accorded to benefits and their realisation will help to promote success, but it’s not enough. It’s vital when Africa’s healthcare resources are very scarce, that benefits exceed costs over time. This creates the more demanding goal of realising net socio-economic benefits. Then, realising benefits is integrated with control of investment, operating costs, obsolescence and risks.

    When eHealth succeeds, the time horizons to net-benefits are long, approaching a decade for large-scale electronic health records (EHRs). Evidence for this exists in tinTree’s eHealth Impact Database, containing cost-benefit data of 60 initiatives from around the world. So, if a decade’s enough time to realise benefits, a reasonable question is what difference will eHealth make over the next ten years?

    The answer is, it depends. Success factors extend across the value chain, including the vision for how citizens’ roles in health and healthcare can change, the way that health workers deal with patients, matching ICT with people and their needs, the scale of investment and the new skills and knowledge that people need.

    eHealth in South Africa, also called ICT4Health, is on a steady trajectory, but is still patchy with much of the current emphasis on administrative data. The emphasis needs switching to health and healthcare delivery and quality. Since the government’s eHealth strategy was finalised in 2012, eHealth globally has seen several significant steps forward that offer bigger benefits than originally envisaged. Analytics and Big Data are topical examples, which South Africa now needs to incorporate into its eHealth strategy. In Africa, expanded mHealth may be one too as the number and use of smart-phones increases.

    A key part of South Africa’s strategy aims to implement EHRs. It provides a sound platform for health worker teams to share patient and clinical information; they’re all up to date and can use the best clinical information to care for their patients. Health informatics can deal with most of the complexity of EHRs and clinical information. There are several examples from other continents that show that this approach is economically viable and achievable.

    It’s now becoming clear that analytics offers the opportunity to make much more effective use of data in EHRs than envisaged some three or four years ago. An example is how it can be used to predict serious deterioration of patients’ health long before traditional diagnostics can see changes.

    This recent surge in the use of analytics is not as well understood and may be the most exciting opportunity over the next decade. It can make health workers more productive and citizens and health workers more proactive, by providing information about changing conditions in people, patient cohorts and environments much faster than health workers can see from observation. An example from the USA is identifying patients with sepsis before health workers can see symptoms, so enabling interventions to avoid deaths in some cases. This leads through to an expanded healthcare model of managing patient cohorts proactively as well as providing direct healthcare.

    Analytics and Big Data can change the way that agencies manage population health. Data from Wikipedia and Google have already provided faster information than the formal health agencies on the spread of flu epidemics in the USA. Twitter is doing the same with HIV. Structuring and transferring interoperable clinical and demographic data from EHRs into population health priorities creates an enormous database for analyses and risk assessment that can improve policies and responses, martialing resources better for better results. It also provides a source of health data for citizens, communities and patients that they can access with continuously improving smart phones.

    If it’s this good, why isn’t it already underway? The answer’s simple. It needs a specific type of strong leadership, sustained investment and targeted change for a few more important pieces to fall into place.

    One requirement is better standards and interoperability across multiple information systems. South Africa’s IOp framework provides an important start, which will need sustained support and development from the standards authority created under the new legislation.

    Another urgent need is a sustained HR plan for investment in health informatics and analytics, with highly skilled people retained and developed further in South Africa: eHealth’s human capital. Supporting this is the need for a substantial, sustainable eHealth investment fund to finance human capital expansion and procure the modern ICT solutions and tools that can provide the information. The goal then is to deploy these to take South Africa’s healthcare forward for the benefit of its 51 million people. Like technology itself, it’s a never-ending quest.

    The terminator was a cyborg-assassin with sinister intentions. Before we have to deal with him, we have to deal with cyber-criminals and their associated threats to the security of our health and healthcare data. Effective eHealth regulation and cyber-security are now essential, not optional eHealth costs. These need developing over the next ten years too.

  • USA's ONC six-year eHealth plan is realistic

    The USA’s Office of the National Coordinator (ONC) has published the Federal Health IT Strategic Plan for 2015-2020. It sets out five goals:

    • Expand eHealth adoption
    • More secure and interoperable information
    • Strengthen healthcare delivery
    • Enhance people’s and communities’ health and well-being
    • Better scientific research, knowledge and innovation.

    It’s based on a set of principles of federal agencies collaborating together and with private stakeholders to:

    • Focus on value
    • Respect individual preferences
    • Build a culture of eHealth access and use
    • Create an environment of continuous learning and improvement
    • Encourage innovation and competition
    • Successfully steward of the country’s money and trust.

    The five goals have their own objectives:

    Expanding eHealth adoption will:

    • Increase adoption and effective use of eHealth products, systems and services
    • Increase user and market confidence in the safety and safe use of eHealth products, systems, and services
    • Advance a national communications infrastructure that supports health, safety, and care delivery

    More secure and interoperable information will:

    • Enable people, providers, and public health organisations to send, receive, find, and use eHealth securely
    • Identify, prioritise, and advance technical standards to support secure and interoperable eHealth and its information
    • Protect privacy and security

    Strengthening healthcare delivery will:

    • Improve healthcare quality, access, and experience through safe, timely, effective, efficient, equitable, and person-centred care
    • Support the delivery of high-value healthcare
    • Improve clinical and community services and population health

    Enhancing people’s and communities’ health and well-being will:

    • Empower people’s, families’ and caregivers’ health management and engagement
    • Protect and promote public health and healthy, resilient communities

    Better research, scientific knowledge, and innovation will:

    • Increase access to and usability of high-quality eHealth information and services
    • Accelerate the development and commercialisation of innovative technologies and solutions
    • Invest, disseminate, and translate research on how eHealth can improve health and care delivery.

    Each of these is set out in detail in the plan. It also says that the “ONC, will implement the Plan and review progress for each goal, including identifying milestones, measurement and reporting tools, and risk mitigation.” This last activity is vital in the light of several USA surveys and reports critical of some of the USA’s EHRs.

    What’s not in the plan are the costs and financial contributions of the partners included in the collaborative models. For eHealth to succeed on a scale that aims to reach more than 316m people and with many stakeholders, explicit, sustainable resource and financing arrangements are vital.

    Resources and finance are often generalised in strategies, which is reasonable up to point. A plan should sit on a firm resource and financing foundation. It’s a valuable reminder for African countries to include it in their eHealth plans. Leaving it out, or to one side, increases the risk of unsustainable eHealth.

  • eHealth leadership's much more than strategy

    Steve Jobs said that “Innovation distinguishes between a leader and a follower.” It may be true, but it’s not enough for eHealth on a tight budget, where strategies have to shift into tactics, implementation, operation, realising benefits and managing risks through each stage: the whole eHealth spectrum.

    Many advisors recommend a national eHealth Strategy as a good starting point for countries wanting to move their eHealth on. It’s good advice. There’s lots of support for those who do, including from WHO with its toolkit, and there’s pressure on those who don’t. Having the strategy, though, isn’t a good indicator that eHealth will fulfill its potential to help to create stronger health systems, or make the difficult task of implementation and realising eHealth benefits any easier.

    tinTree’s absorbed by these questions across the whole profile. The wrong answers can break a good eHealth strategy. A tinTree study is identifying what helps countries move forward, what obstacles need to be overcome and what makes the biggest, affordable difference. Some of this is in tinTree’s African eHealth Readiness Index. The result is what appears to be an optimal position between solving problems and taking new opportunities, dealing adequately with affordability and capacity, and ensuring the right leaders are in place across the eHealth spectrum. These are essential for a good start. They’re the strategic priorities and before success is tasted, eHealth needs them converted into initiatives that are driven directly by stakeholder spreading throughout the health system.

    A recent report covered by eHNA, says that only 4% of US hospitals have ICT infrastructure ready for integrating types of eHealth. It’s a surprise to many of us. The US is known for its strong strategies and ICT investment, particularly around integration, but somehow the strategies didn’t convert into the eHealth spectrum that needs expanded ICT capacity. The reasons are numerous. One could be leadership.

    Some laudable parts of a good strategy might not deal adequately with the dynamic and complex pressures experienced by implementers, who have their own goals and strategies and ideas about how best to achieve them. If they are not sufficiently involved in the high level strategic choices, there could be a mismatch of priorities that constrict progress.

    eHealth leadership is  a bigger challenge than previously thought. It’s always been an eHealth Strategy topic, a box to be ticked, but its obstacles are often underestimated. The skills, knowledge, attributes, tools and data needed for good leadership and its decisions are substantial. To expose the eHealth choices to be weighed and considered with stakeholders, leaders need rigorous eHealth impact models and appraisals that identify the various paths likely to achieve buy-in, secure benefits, and deliver a positive impact.

    A witty Malawian proverb offers advice. “He who thinks he is leading and has no one following him is only taking a walk.” This is the critical test for eHealth leaders moving from strategy to implementation.

  • MomConnect offers a sound focus for SA's eHealth strategy

    South Africa is a fertile home for new mHealth, with a number of initiatives underway. A new one is emerging that’s set to be important.

    MomConnect provides continuous links with pregnant women. The partners are UNICEF South AfricaVirtual PurplePraekelt Foundation and the provincial Department of Health in KwaZulu-Natal (KZN). It’s an SMS based project.

    It’s part of the South African National Department of Health’s nationwide maternal mobile health system due for launch this year, as reported by Africa Health It News. The efforts contribute to the campaign on Accelerated Reduction of Maternal and Child Mortality in Africa (CARMMA), and aim to register 1 million pregnant mothers into a national public health database.

    GSMA describes MomConnect as an “SMS-based project that aims to remind pregnant mothers about critical clinic visits during pregnancy, as well as check-ups and immunizations until the child is 18 months old.

    South Africa’s Minister of Health Dr Aaron Motsoaledi describes MomConnect as one of a number of important steps underway to reduce South Africa’s maternal and child mortality by improving communication with the 1.5 million women who become pregnant every year. “This service will enable us to send SMS messages to every registered pregnant woman.” He told parliament on 19 June 2014.“The messages will be appropriate to the stage of pregnancy and will advise them on what to do at that stage. It will also advise them on how to take care of their newborn.”

    It’s an ambitious programme that fits the passionate leadership style and service focused approach of the minister. “Apart from us sending messages to them, they will also be able to send us SMS messages,”  he adds, “about the problems they encounter when they try to access health services. They may also call to compliment the health facility if they think the service they received was good.”

    One of the challenges faced by South Africa’s Prevention of Mother-to-Child Transmission (PMTCT) is to provide a continuum of care to HIV positive pregnant mothers and their children from antenatal to postnatal periods.

    MomConnect aims to close the gaps in the continuum of care, using mobile technology linked with patient electronic medical records to support PMTCT, including the improvement of maternal and child health outcomes. A pilot has been running in selected KZN facilities since 2011.

    Otty Mhlongo’s is a PMTCT manager in KZN. She presented at last year’s South African Aids Conference where she said,“MomConnect aims to improve Maternal & Child Health, and ultimately eliminate paediatric HIV transmission through the use of on-going SMS messaging to the mom.”

    The pilot tests the efficiency of personalised, unique antenatal and postnatal SMS reminders to 6,000 pregnant women, irrespective of their HIV status, in two KZN districts. It showcases MomConnect’s ability to enable early recognition of HIV positive women with a low count of CD4 cells, white blood cells that help maintain the body’s immune functions, who require Anti-Retroviral Treatment (ART). Regular, tailored supportive messages and reminders during antenatal and postnatal periods, the facilitation of clinic visits for mothers and babies and the improved communication between patients and treatment providers add considerable benefits to health and healthcare effectivness.

    Messages will be in six languages at its launch, with plans to ultimately accommodate all of South Africa’s 11 official languages. It’s a substantial undertaking.

    Scaling up MomConnect is an important project. It’ll need high levels of Semantic Interoperability (SIOp) and Health Information Exchange (HIE), possibly and bi-directional levels to support information flows, EHRs and population health services. These two facilities often need an expansion in ICT capacity to support in the increased traffic that this type of scale-up needs. Dealing with these eHealth technicalities in a patient setting is a good way to proceed.

  • The USA's eHealth strategy offers lessons for Africa

    Virgil, the ancient Roman poet, not the Thunderbirds pilot, said “Who asks whether the enemy was defeated by strategy or valour.”  Karen DeSalvo, head of the USA’s Office of the National Coordinator for Health Information Technology (ONC) may have a different view. Healthcare IT News has reported that her top priorities are:

    1. Improved interoperability: the top priority
    2. Increase end user adoption of health ICT
    3. Establish standards so the various technologies can speak to each other
    4. Provide the right incentives for the market to drive this advancement
    5. Make sure personal health information remains private and secure
    6. Provide governance and structure for health ICT.

    Achieving  the USA’s three top healthcare aims needs all of these in place. The aims are:

    1. Improving healthcare experience
    2. Improving population health
    3. Reducing per capita costs.

    Healthcare IT News reported on the need for better interoperability in a separate article. It says that the limitations of current interoperability levels is hindering efficiency and damaging enthusiasm.

    The clarity of DaSilvas’ strategic goals offers a good lesson in strategic clarity. It is much better than relying on Virgil’s role as Dante’s guide through hell and purgatory.

  • Fourteen points for a social media strategy

    Why January is a time for reassessment and reflection is an ancient custom is because of its link to renewal. It could also be because in the Northern Hemisphere, the temperature is too low to do much else other than think. In the Southern Hemisphere, it could be because the temperature is too high. These two explanations seem a bit improbable.

    Strategically, it has the same relevance as the other 364 days. With the burst of new eHealth opportunities, it is as good also as good as any other day, and with the rapid evolution of social media, any day is a good time.

    Simply Measured, a USA firm providing social media analytics and measurement, has posted 14 steps for a new social media strategy for 2014. They are:

    1 Start with a 2013 summary

    2 Have a plan

    3 Set SMART goals: Specific, Measurable, Attainable, Relevant and Time-bound

    4 Spy on the competition

    5 Create an editorial calendar

    6 Align with your marketing goals

    7 Marshal your resources

    8 Develop a strategy for execution

    9 Build in some backup

    10 Give yourself some wiggle room

    11 Consider more visual content

    12 Optimize for mobile

    13 Embrace diversity

    14 Track and measure everything.

    The Simply Measured checklist offers a good start for African countries, and shows the potential to put this alongside their mHealth strategies and plans. It makes mHealth strategies more up to date by following the social media curve and increasing their impact.

  • National eHealth strategies crucial for universal health coverage and MDGs 4 and 5

    In Dakar, Senegal on 28 October 2013, an international three-day workshop at TerrouBi Hotel reviewed developing national eHealth strategies. It was jointly organized by the International Telecommunications Union (ITU) and the World Health Organization (WHO), and  aims to facilitate the development of comprehensive eHealth strategies using the National eHealth Strategy Toolkit developed by the WHO and ITU.

    The Commission on Information and Accountability for Women’s Health and Children (CoIA) was created in January 2011 to encourage further commitment to the health of women and children and ensure that resources are spent as efficiently as possible to save lives. One of CoIA’s ten recommendations is to “encourage innovation through information technology and communication (ICT) for accountability.” The WHO and the ITU both support this recommendation.

    In many countries, the integration of ICT in health systems is incomplete and must be planned at the national level to ensure that existing resources are used optimally and that these technologies provide a solid basis for investment and innovation. A national eHealth strategy supports health development and strengthens health outcomes. It also plays an important role in implementing CoIA recommendations.

    Dr Diarra Nama, Senegal’s WHO representative, and Mr Diadié Touré, from the ITU Regional office for West Africa opened the workshop. They acknowledged the great progress made on the continent, emphasizing the use of mobile technology to expand the reach of health information and services. They officially presented the jointly developed National eHealth Strategy Toolkit.

    For many African countries, eHealth remains challenging. eHealth programmes are often implemented in a fragmented manner due to lack of national strategy. The workshop provided participants from French speaking African countries such as Burkina Faso, Ivory Coast, Cameroon, Madagascar, Mali, Mauritania, and Senegal with the relevant tools to address this. The Toolkit is a comprehensive and practical guide that all governments can adapt for their specific contexts. In Senegal the development of a national eHealth strategy has already begun, but the workshop has strengthened the on-going process and its outcomes.