• Systematic Reviews
  • Five main insights on the impact of EHRs can help investment plans

    While EHRs provide the most comprehensive, up-to-date patient information, more details about their impact’s needed for investment decisions. eHealth investment challenges are:

    What benefits to they bringHow are they realisedHow long does it takeDoes their value exceed their costs.

    Spectralink describes insights into some of these in its technical brief Five ways EHRs improve healthcare delivery. It’s available from EHR Intelligence. The five generic ways are:

    Access to critical data, anytime, anywhereImproved care coordinationMore accurate diagnosticsIncreased work flow efficiencies and cost savingsBetter patient participation.

    Within these five, ten benefits are identified across two groups:

    Physician workflow              

    Accessed patient chart remotely - 74%Alerted to critical lab value - 50%Alerted to potential medication error - 41%Reminded to provide preventative care - 39%Reminded to provide care meeting clinical guidelines - 37%Identified needed lab tests - 28%Facilitated direct communication with patient - 25%

    Patient-related outcomes   

    Enhanced overall patient care - 74%Ordered more on-formulary medications  - 41%Ordered fewer tests due to lab results availability - 29%

    Three other activities show large impacts: 

    Note practice functions more efficiently - 79% Receive lab results faster - 75%Report enhances in data confidentiality - 70%. 

    While these are large increases, there’s no information about how much more efficiently, fasters of enhancing these changes were. These estimated values are important in evaluating EHRs’ impacts. 

    None of the benefits refer to increased patient access as part of Universal Health Coverage (UHC). This needs resources liberated by efficiency gains to be redeployed to communities with no or limited UHCs. Acfee reviews reveal that these seldom happens on a large scale with EHRs. It has to be linked to specific UHC initiatives. 

    Uploading information with mHealth links are in place in about two-thirds of EHRs. This offers scope for further investment. It’s an essential feature for Africa’s eHealth

  • Promising future for eHealth in Africa, despite lower than expected growth
    Growth in the eHealth sector has failed to meet initial high expectations, but start ups are starting to gain traction as obstacles are removed.

    Africa’s eHealth sector has always attracted investment, but o far failed to live up to the market’s high expectations. Is change in the air? Disrupt Africa’s latest Africa Tech StartUps Report shows that ten eHealth start ups raised close to USD$9.5 million in 2017, up from USD$8.3 million in 2016. A report from Disrupt Africa summarises the main themes.

    This increase reflects Africa’s health market’s continuing potential for disruption. Nic Klopper, CEO of the hearX Group, a South African based company which develops smart phone hearing solutions, believes that clinical and traditional solutions aren’t meeting African market requirements because they’re prohibitively expensive and static. It means they can’t assist with decentralised healthcare programmes. By changing the way healthcare’s delivered, eHealth solutions are reaching people at the grassroots.

    However, any eHealth project must first find solutions to Africa’s specific social and physical environment to stand a realistic chance of success. So far, the path to growth in the eHealth sector has not been without pitfalls.

    Rob Heath, a South African investor at HAVAIC, says a main obstacles to growth was a of tech-savvy locals to carry projects over the finishing line. Quality’s good, but numbers aren’t. There’s a lack of professional investors who can add real value too.

    Another major obstacle was difficulty in achieving scale. It makes investors hesitant. Yet there are signs that start ups are now beginning to overcome this.

    The key is in the data. While African eHealth solutions meet local solutions, they provide data of global significance which can be sold on the world market.  An example’s Zipline, a drone-based blood delivery service in Rwanda. It  could supply data to organisations on other continents, so the US Federal Aviation Administration could obtain a drone delivery licence based on its data from Rwanda, or use its technology in a disaster relief zone.

    This potential for international growth is a major factor for investors. It’s essential in enabling start ups to achieve scale, which in turn means they’re taken up by the market. This closes a virtuous cycle; scalability attracts investors which allows scalability.

    Siraaj Adams, CEO of Digital Health Cape Town, a dedicated eHealth accelerator programme, says eHealth’s a sector that’s now attracting the much-needed attention it needs. He sees a bright future. Start ups in Africa find solutions for specific issues within their immediate environment. Scalability with the right backing can become a reality. Plummeting hardware and software costs means the cost of rolling out eHealth projects is becoming more affordable. It enables net benefits AI’s in the frame too plugins, web-hosted servers, and natural language processors can turn good ideas into products very quickly and affordably.

    eHealth’s future looks promising. Africa needs mHealth and cost-effective solutions delivered in communities, but it’s their value to the international community that will provide funding streams to turn these visions into action. 

  • US EHR solution judged not up to the job

    eHealth has risks. A report from the US Office of the Secretary of Defense, and available from EHR intelligence, highlights some of these. They provide valuable themes for Africa’s health systems to use in their EHR assessments and procurements. Is says “a partial  IOT&E [Initial Operational Test and Evaluation] was adequate to determine that MHS GENESIS was neither operationally effective nor operationally suitable.” It raises an important challenge: how could this have been established before procurement? 

    Inappropriate performance included: 

    MHS GENESIS is neither operationally effective nor operationally suitable. DOT&E recommends that the Under Secretary of Defense for Acquisition and Sustainment delay further fielding until JITC completes the IOT&E and the PMO corrects any outstanding deficiencies. Detailed recommendations are included in the main body of this report;

    It doesn’t demonstrate enough workable functionality to manage and document patient care in 56% of the 197 tasksof performance Poorly defined user roles and workflows increased the time needed for health care providers to complete daily tasks, including overtime and seeing fewer patients a dayUsers questioned information accuracy in exchanges between external systems and MHS GenesisPoor usability of 37%, on the System Usability Scale (SUS), well below the 70% thresholdInsufficient trainingInadequate help desk supportSystem unplanned downtime outages indicated that the end-to-end system and supporting network didn’t have sufficient availability to support operations at the four IOT&E locationsUsers reported increased lag times when other IOT&E sites went live, suggesting the supporting network configuration wouldn’t support the hundreds of additional planned sitesSurvivability is undetermined because cybersecurity testing isn’t complete. 

    This salutary experience shows the importance of rigorous assessment processes before procurement. Across the global eHealth community, it’s not the first time, and it’s not likely to be last. Africa’s health systems can afford this type of risk exposure experience. 

  • mHealth’s proven impact still seems elusive

    Africa has an expanding, diverse mHealth core to its eHealth initiatives. The Journal of Medical Internet Research (JMIR) found limited evidence of mHealth’s impact, and hinted that in low-income countries, mHealth’s still at an early development stage.

    JMIR’s systematic review covered 10,689 mHealth articles, including 23 systematic reviews of 371 studies with over 79,609 patients. Seventeen reviews included studies of low- and middle-income countries’ initiatives. 

    SMS for a wide range of purposes seems to be the most common type of mHealth. It includes reminders, alerts, educations, motivation and illness prevention. Ten reviews gave them an Assessment of Multiple Systematic Reviews (AMSTAR) score of 0 to 4, low quality. Seven were rated as moderate quality, an AMSTAR score of 5 to 8. Six were rated as high quality, an AMSTAR score of 9 to 11. 

    mHealth for  chronic disease management scored well for impacts of:

    Improved symptoms and peak flow variability in asthma patients and fewer hospital admissions and improving forced expiratory volume in one secondImproving Chronic Obstructive Pulmonary Diseases (COPD) symptomsImproving heart failure symptoms and fewer deaths and hospital admissionsImproving glycaemic control in diabetes patientsImproving blood pressure in hypertensive patientsReducing weight in overweight and obese patientsBetter attendance ratesBetter adherence to tuberculosis and human immunodeficiency virus therapy in some scenarios, with evidence of decreased viral loads.

    While these are positive results, the benefits may still be moderate.  JMIR concluded that “Evidence for efficacy is still limited. In general, the methodological quality of the studies included in the systematic reviews is low. For some fields, its impact is not evident, the results are mixed, or no long-term studies exist.”

    The lack of reliable evidence doesn’t mean that Africa should slow down its mHealth investment. Instead, it means it should set up a reliable methodology to reveal the range of good and bad impacts. Lessons from these will be invaluable.

  • eHealth for mental health needs more intelligence

    Cinderella never thought that her success would attach her name to parts of healthcare. Countries’ mental health service is one of them, and its eHealth investment is being held back too. A study in the Journal of Medical Internet Research (JMIR) sets out to explain why. It investigated individual characteristics that influence both preferences and intentions to use eHealth for mental health in Australia. It identifies factors that might inhibit or enable eHealth.

    It found low reported preferences for eHealth for mental health services. Despite this, intentions to access these services are higher. This raises the challenge of how to translate these intentions into activities that use eHealth services. It found that strategies designed to enhance confidence and familiarity and ease people into new Internet-based mental health service programs may be important for increasing the chances of sustainable use. But, will users return to eHealth later? 

    It’s a worthy goal, but the study found that most respondents, almost 86%, prefer face-to-face services. The scope to engage eHealth users was found to be up to 40%. It’s a significant user base that needs supporting.

    Acfee identifies several factors that needed in eHealth to secure benefits. They include:

    Stakeholder engagementMeeting users’ information requirementsEasy to useHigh level of utilisation. 

    Putting these in place for the 40% will increase the chances of sustainable use and benefits realisation. For Africa, with its limited healthcare resource base, supporting up 40% mental health patients with eHealth access offers a valuable way to expand mental health services at minimal cost. It’s an opportunity. It’s not easy to achieve.

  • A portal doesn’t improve US hospital outcomes

    As the internet and web have spread across healthcare, portals have been seen as an essential link between patients and clinical teams. It seems they don’t make any difference to hospital outcomes. A study at Mayo Clinic Hospital, Jacksonville, published in the Journal of the American Medical Informatics Association (JAMIA), found the 30-day re-admissions, inpatient mortality and 30-day mortality rates were virtually the same for hospital patients who used portals without prompting and those who didn’t have accounts to use them. The 30-day rates were adjusted for Lengths of Stay (LOS).

    Interpreting the results needs to incorporate the limitations of the portal. It has no specific features for communication between patients and healthcare teams. It only includes admission notes, operative notes, consultations and laboratory studies in real time. Daily progress notes can’t be viewed, and there’s a 72-hour delay in viewing radiology and pathology reports. There’s no educational material about patient-specific diseases and processes.

    Patients with portal accounts seem to drop their access on admission. About 44% of patients who had a portal account when they were admitted, but fewer than half, about 21%, accessed it when they were inpatients. Other studies have found similar results, such as 34% and 23%. For tertiary services, the rates were 25% and 16%.

     of registered users accessed their account.22 The lack of features designed specifically for inpatient use was previously emphasised in a systematic review.14 Consequently, several medical centres designed hospital-specific applications aimed at improving the use and usability of inpatient portals.23–25 In a realistic review, Roberts indicated that patient participation with inpatient health information technology (including patient portals) can be augmented by interactive learning focused on information sharing, self-assessment and feedback, tailored education, user-centred design, and user support. Outpatients with severe diseases use portals more frequently. 

    Patients who access portals have better outcomes for some chronic conditions such as: 

    ·             Diabetes, with lower haemoglobin (HbA1c) after 6 months

    ·             Hypertension, with improved blood pressure control at 12 months)

    ·             Depression management, with increased medication adherence

    ·             Preventative care, such as up-to-date immunisations and mammograms. 

    Portals can have benefits. African health systems need to be explicit about what their portals can achieve and ensure that these are maximised.

  • Telemedicine helps type 2 diabetics

    As the cases of diabetes type 2 increase, a systematic review by Dr Rashid Bashur from the E-Health Center, University of Michigan Health System, and his colleagues, published by Liebert, says telemedicine can help. Its findings are “The major contributions point to telemedicine’s potential for changing behaviors important to diabetes control and prevention, especially type 2 and gestational diabetes. Similarly, screening and monitoring for retinopathy can detect symptoms early that may be controlled or treated … Overall, there is strong and consistent evidence of improved glycemic control among persons with type 2 and gestational diabetes as well as effective screening and monitoring of diabetic retinopathy.”

    The study reviewed 73 research articles on the outcomes of telehealth use for diabetes control. It analysed different patient populations, technologies, resources and research protocols. Other findings were:

    Telemedicine for diabetes can be effective for rural patients A 29% increase in adherence to prescribed glycemic tests by patients when nurses called patients to remind them Decreases in A1c levels and cardiovascular risk factors with an electronic disease management system and a home care link to send messages for Type 1 or Type 2 diabetes.

    The study provides evidence for African countries to use in assigning priorities to their telemedicine initiatives. It could overlap as good practices for some mHealth projects too.

  • What works and doesn't for mHealth in Africa

    mHealth is often promoted as a big part of the eHealth contribution for stronger healthcare in Africa. The potential is good, but not all mHealth is good mHealth. While this is obvious for all eHealth, the challenge is to know the difference before it’s implemented. A study in Medscape, Systematic Review on What Works, What Does Not Work and Why of Implementation of Mobile Health (mHealth) Projects in Africa, can help.

    It uses SWOT analyses, the widely known strengths, weaknesses, opportunities, and threats, to review 44 peer-reviewed publications on mHealth over the ten years 2003 and 2013. It focused on sustainability, medium and long-term results, integration to health systems, management process, scale-up, replication, legal issues, regulations and standards.

    It’s mHealth groups were:

    19 for patient follow-up and medication adherence 10 for data collection and transfer and reporting 4 for staff evaluation, monitoring and guidelines compliance 4 for disease surveillance and intervention monitoring 2 for staff training, support and motivation 2 for drug supply-chain and stock management 2 for overview of mHealth projects 1 for patient education and awareness.

    A common theme was that mHealth projects succeeded if they had accessibility, acceptance, low technology costs, effective adaptation to local contexts, strong stakeholder collaboration, and government involvement.

    There were several significant threats. Funding dependency, unclear healthcare system responsibilities, unreliable infrastructure and lack of evidence on cost-effectiveness are challenges to successful implementation.

    The main features of an effective mHealth project in Africa are seen as:

    Good project design adapted to local contexts, promotion, education and awareness of the project Technology and resources that use local resources, capacity building, availability and maintenance Stakeholder involvement across public-private partnerships, multidisciplinary teams, ministries of health, political leaders and local champions Government eHealth and mHealth departments engaged in programme monitoring, evaluation and research.

    A conclusion is that mHealth projects are not a solution to the challenges that health systems face in many African countries. Evidence remains poor, and results are still specific and constrained to projects or setting. Questions regarding impact, scalability and increased coverage remain, such as transferability to different diseases, different settings and different target populations. Questions over cost-effectiveness and sustainability of projects in Africa still remain. While mobile phone technology continues to improve, more research on these areas is essential to understand mHealth’s potential and help to reach the hard isolated and marginalised communities.

    The study provides a strong and constructive challenge to all mHealth decision takers in Africa. Responding to it isn’t too difficult.

  • Invaluable USA research on eHealth impacts

    The literature review Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Use Functionalities is extremely valuable. It’s the antithesis of Earl Landgrebe’s daft remark at the Watergate hearings: “Don’t confuse me with the facts.” The review of 278 studies from 2011 up to 2013 was prepared for the USA’s Office of the National Coordinator for Health Information Technology (ONC) and completed by the Southern California Evidence-based Practice Center of the RAND Corporation. Whilst its focus was the USA meaningful use definition, the findings are widely applicable to eHealth in other countries.

    The study reviewed three themes. They were the effect of eHealth on healthcare’s:

    Efficiency Quality Safety.

    Safety is an essential part of quality, but the review treats it separately.

    A most striking finding is that “Functionalities included in the Meaningful Use regulation, can improve healthcare quality and safety. The relationship between health IT and efficiency is complex and remains poorly documented or understood, particularly in terms of healthcare costs, which are highly dependent upon the care delivery and financial context in which the technology is implemented.”

    It also points out the essential relationship between ICT and change for benefits realization. It says that of the ninety-two studies on the effect of eHealth on process quality, “The great majority of studies reported positive outcomes for process quality measures, not all studies did so, and most studies lacked sufficient detail to determine which factors may have led to the lack of benefit found in those studies. Our review found that single-site studies typically provided more specificity about the health IT interventions than did multi-site studies. Single-site studies also provided more detail about the context and complementary factors that may enhance the efficacy of the health IT or contribute to the success of the implementation. The small number of studies that seemed to account for contextual and complementary factors tended to show that health IT can have significant positive effects on process quality if the technology is implemented in combination with process changes that leverage the capabilities of the health IT.”  

    Another finding that may help dispel an inappropriate view of eHealth as a means of reducing healthcare cost is that “Cost effects ranged from a 75 percent decrease to a 69 percent increase in the targeted costs; however, many of the studies clustered in the range of six percent to 12 percent increases in the targeted costs. These findings suggest that layering technology on the existing payment system may not result in lower costs.”

    Assessing these aspects rigorously should be at the core of all decisions on eHealth initiatives.

    iHealthBeat has a good summary of the study. The review showed:

    77% with positive or mixed-positive outcomes 45% with had overwhelmingly positive outcomes 20% had negative outcomes.

    Specifically on patient safety:

    67% had positive results 17% had negative results.

    Armed with this study, no one can say they’re confused by the facts.

  • Telemonitoring evaluations can be better

    Research published in the Journal of Medical Internet Research claims that many telemonitoring appraisals do not comply with recognized guidelines and standards. Some methodological limitations identified in the study results affect the results and conclusions of some evaluations.

    The research team concluded that, “Despite the availability of methodological guidelines that can be utilized to guide the proper conduct of systematic reviews and meta-analyses and eliminate potential risks of bias, this knowledge has not yet been fully integrated in the area of home telemonitoring.

    The study found that the number of published reviews has increased substantially over the years, but the focus was mainly on home telemonitoring of patients with congestive heart failure. Other chronic diseases such as diabetes, hypertension, chronic obstructive pulmonary disease (COPD), and asthma have less emphasis.

    The study’s findings are that many reviews appear to lack optimal scientific rigor due to methodological issues and their overall quality does not appear to have improved. Evaluations did comply with several criteria satisfactorily, such as establishing an a priori design with inclusion and exclusion criteria, use of electronic searches on multiple databases, and reporting studies characteristics. But, other important areas need improvement, including duplicate data extraction, manual searches of highly relevant journals, inclusion of grey and non-English literature, assessment of the methodological quality of included studies and the quality of evidence.

    It seems that progress on evaluations may be slow. Criticisms go back to Whitten’s review on telemedicine evaluations in 2002.