• Strategy
  • Burundi eHealth strategy's out

    As the African eHealth Forum was assembling its long schedule of eHealth opportunities and challenges at the end of July, Burundi’s Health Ministry was finalising its Plan National de Développement de l'Informatique Sanitaire (PNDIS), available on the Resources tab of eHNA’s Burundi page. It sets out its eHealth challenges and health information strategy for the next five years. It’s a substantial document and important contribution to Africa’s eHealth. It builds on its Plan Stratégique du Système National d’Information Sanitaire 2011 - 2015, and it’s ambitious.

    It includes the use of standards, including:

    International Classification of Diseases Tenth Revision, Classification Internationale des Maladie (CIM 10), Classification of Primary Care, La Classification Internationale des Soins Primaires (CISP-2) Diagnostic and Statistical Manual of Mental Disorders, Le Manuel Diagnostique et Statistique des Troubles Mentaux (DSM) Bilingual Bi-classified Terminology (3BT) thesaurus Logical Observation Identifiers Names and Codes (LOINC) Anatomical Therapeutic Chemical Classification, Le Système de Classification Anatomique (ATC).

    It assesses architecture in two parts. They’re first, information systems and applications, second, technology strategy.

    Burundi sees its eHealth challenges as including:

    eHealth fragmentation Over-reliance on donor funding Low uptake of ICT projects in the health sector Sustainability Limited government leadership No ICT framework.

    The total estimated spending on PNDIS is more than €18 million, over €3m for each of the next five years. Nearly €7m of the total’s for Priority 1 projects.

    When the strategy and plan’s finally approved, it’ll be a big step forward for Burundi. It may well extend beyond a five year horizon.


    Image from the strategy's cover

  • South Africa's new mHealth strategy's out

    There’s big news out of South Africa. The official mHealth Strategy 2015-2019 has been released by the National Department of Health. You can find it on eHNA's South Africa Resources page or download it here.

    The strategy’s been over a year in the writing, and after several iterations, is now finalised and approved by the Health Minister, Dr Aaron Motsoaledi and Director General, Ms Malebona Precious Matsoso. mHealth's evolution is an "opportunity to deliver improved health services" emphasises Dr Motsoaledi.

    The mission of the strategy is to 'apply mHealth as an integral part of delivery of health care services in order to meet information communication, health education and data management needs of the health system in South Africa.”

    Its aim is to provide a single harmoniszed and comprehensive mHealth strategy and implementation plan that:

    Supports the priorities of the health sector Addresses and meets the needs of: Individuals, so they’re empowered to maintain and promote their own health and that of their families and communities Providers of healthcare services Managers and policy makers  Paves the way for future public sector mHealth requirements.

    The strategy examines the current mHealth environment, research and piloting, and legal and policy framework. Like most countries, South Africa lacks an overarching legal framework for eHealth and mHealth. Nevertheless, South Africa has legislation to protect patients’ health records, a critical element. It’s provided for in the National Health Act (61 of 2003) that includes the electronic transmission of personal medical information networks.

    There's an mHealth Roadmap too, which has articulations with South Africa's National eHealth Strategy 2012.

    Challenges are discussed, the main ones encountered in South African being:

    Lack of alignment and integration of the intervention into health plans, strategies and systems Absence of government leadership and coordination Poor documentation and learning from best practices Lack of use of open source options Absence of practical approaches to privacy and security Lack of interoperability Absence of a single framework within which to evaluate the role of mHealth and eHealth tools to strengthen the health system.

    As mHealth continues to expand across Africa, these challenges need addressing. These, and numerous others, were discussed in detail at Acfee’s African eHealth Forum, held in Cape Town last week. Some have simple solutions, others are more complex. Acfee believes that eHealth leadership and capacity building at all levels will play a major role in addressing many challenges. Another aspect highlighted was the need for better communication between countries regarding their mHealth experiences. Learning from each others successes, as well as failures, is crucial for successful eHealth. 


    Image thanks to Amanda Tanner

  • How should you implement your mHealth strategy?

    Just because mHealth’s good for Africa doesn’t mean it’s easy. Converting strategies into action is always difficult, especially in Africa’s constrained ICT and healthcare environment. A white paper from Common Time sets out some steps that help to smooth the way. First, recognise the benefits. They include:

    Better, smarter and more patient-centric healthcare Reduced risk having the right information at the right time Better data capture EHRs Less worker downtime Cost savings.

    From these, the challenges are then dealing with a daunting list of:

    Selecting platforms, devices and types of app Engaging users Leveraging legacy ICT Offline working App development processes Deployment pace Adequate and skilled resources Interoperability Data management and manipulation Data synchronisation Multi-lingual capability Infrastructure Security.

    You then have software deployment choices of making it yourself, leveraging industry standards or taking a platform approach. With a platform, the report suggests the need for a Mobile Application Development Platform (MADP). It integrates management, development and collaboration. When it’s finished, you can use it to test your requirements. There are twelve questions, does the MADP:

    Support the development of single source apps using open standards? Support the development of apps for organisation to patient, organisation to supplier and organisation to public interfaces? Support distribution through an enterprise app store, third party app stores and Mobile Device Management (MDM) solutions? Provide a framework for user interface and experience design to create user-friendly apps? Enable organisational stakeholders to contribute to app development? Support open technologies so can leverage their existing skill-base? Enable developers to produce new software components and controls for re-use? Provide analytical and debugging tools for good software versioning control and auditing? Support offline and online working? Support flexible deployment options, such as cloud Support open integration to mobilise legacy and cloud enterprise systems? Support data management to facilitate interoperability?

    Creating successful mHealth’s a big job, and it doesn’t tell you how to make you mHealth programme affordable. Only you can do that.

  • Five ways to transform healthcare

    At the African Centre for eHealth Excellence (Acfee), eHealth’s seen as a combination of people, health ICT and healthcare transformation. This view’s developed further at the 4th European Forum on Health Policy and Management: Innovation & Implementation in Berlin, where they’ve been discussing transformation needed for successful innovation. They identified five challenges:

    Beyond technology, because healthcare needs social innovations that lie beyond the technological and clinical Population health that successfully manages the health needs of large populations Professional buy-in that grows with innovation’s increasing pace Deciphering evidence, including ethnographic questions about populations, such as who are they, how do they live, how do they see health and health care and what are their problems? A new generation seeking personalised medicine, health information from the Internet, keen to share decision-making with providers, anxious about information privacy and intrigued by wellness and technical medical innovation, but alongside communities in poverty, illiteracy, stigma, and personal and social disorganisation who remain beyond innovation’s reach.

    These themes fit Africa’s eHealth challenges. They offer a start to develop eHealth’s clinical, executive and political leaders to develop a toolkit to help them transform and improve the health of their communities and the services provided by their healthcare systems.

  • 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.