• Systematic Reviews
  • AMA has a structure for choosing EHR providers

    Procurement sits between EHR strategy and implementation. It’s a challenging process and needs a rigorous structure to assess providers and choose a few to move on to a procurement short list, The American Medical Association (AMA) has a checklist that helps to find a vendor worthy of a long-term partnership. It’s step 4 in the Part 2, the Pre-Game section of the American Medical Association® Digital Health Implementation Playbook.

    Selecting and Vendor Guide aims to find a long-term partner, not just an organisation to execute a set of transactions. Speaking with similar organisations or practices can provide valuable information and insights needed to construct shortlists of quality vendors. eHealth conferences can be another source.

    Discussions are not enough. Structured market research and activity’s needed too. AMA suggests: 

    Build a Request for Proposal (RFP) that clearly outlines the goals that define successSend RFPs to vendors that most closely align to these goals Review RFP responses alongside key representatives from core and advisory teamsAsk for case studies and referrals Schedule live vendor demonstrations with members of the core, advisory and implementation teamsEvaluate vendors across six critical factors:

    o   Business

    o   ICT

    o   Security

    o   Usability

    o   Customer service

    o   Efficacy and clinical validation

    Narrow options to one or two preferred vendors in the pitch to leadership.

    Usability includes interoperability. Efficacy includes the vendors’ abilities to deliver organisational goals, metrics and Key Performance Indicators (KPI). For large-scale, strategic investment lick EHRs, three options may be more appropriate in revealing the differences between vendors’ technical services and cultures that are available. 

    AMA’s playbook can help Africa’s health systems to enhance the structure and sustainability of moving their EHR projects from investment decisions towards implementation. Procurement’s tough. Vendors are smart and used to the processes. AMA’s guidance helps to rebalance them.

  • A study designs a model to manage eHealth evaluation

    eHealth evaluation isn’t a common activity. A study in the Journal of Medical Internet Research, says the importance of evidence hasn’t been discussed as rigorously as the diverse research approaches and evaluation frameworks have been discussed.

    From this position, the team’s objective was to elucidate how evidence of eHealth effectiveness and efficiency can be generated through evaluation. It developed a model to help. Evidence in eHealth Evaluation comprises:

     

    It aims to show how evidence can be generated by evaluating certain aspects at each intervention phase. Assessing distinct aspects during distinct phases is a novel concept discussed in this study and requires further analysis.

    It’s consistent with Digital Health Impact Framework (DHIF) designed for the Asian Development Bank (ADB) and Standards and Interoperability Lab Asia (SIL-Asia). It also has some differences. DHIF. For example, DHIF includes optimism bias and risk exposure, and emphasises the different impacts, especially benefits, across a range of stakeholder types.

    The study implies an inconsistency between literary eHealth evaluation concepts and practices. It

    found that eHealth evaluation isn’t common in design and pretesting phases. Acfee’s view’s that it isn’t common before these, at the strategic and business case decisions stages that seek preferred options that commissions designs. It’s also rarely used at eHealth procurement stages. 

    It seems feasible to stretch Evidence in eHealth Evaluation model to include eHealth components on a wider timescale. Adding extra components within its timeline seems possible too. It is a conceptual model in its preliminary stages, so still being developed. It’s not a prescription, but a way to show a reliable progression of evidence in eHealth intervention. Africa’s health systems could build from it too.

  • Patients rely on health information on the Internet

    Trusting doctors is a crucial requirement of successful healthcare. The Internet has added a variable into the relationship between patients and their doctors compared to the traditional set up. An empirical study by a team from China and the US in the Journal of Medical Internet Research (JMIR) investigated the effects of the quality and source of Internet health information on patient compliance. It relied on social information processing and social exchange theories.

    Relationship Between Internet Health Information and Patient Compliance Based on Trust: Empirical Study found that the quality and source of health information from the Internet affects patients’ compliance through the mediation of Cognition-based trust (CBT) and Affect-based Trust (ABT).

    Consequently, patients’ compliance can be improved by strengthening the quality of health information management on the Internet. It also suggested that doctors should obtain health information from health websites to expand their understanding of patients’ knowledge of their conditions and their compliance with their treatment regimes.

    More specifically, the mutual demonstration of care and respect in physicians’ and patients’ communication’s important in promoting patients’ ABT in their physicians. CBT doesn’t have any direct effect on patients’ compliance, but directly affects ABT, then indirectly impacts patient compliance.

    For Africa’s health systems, the study emphasises the need to invest in high quality, accurate, sustained Internet health information. Setting up the service with minimal operational resources may be unhelpful and disruptive.

  • Argentina’s health system aims to balance information needs and privacy

    Balancing competing claims in health systems never ends. Simon Sinek, an author, says “There’s no decision that we can make that doesn’t come with some sort of sacrifice or balance.”  So it is with eHealth. In an interview in eHealth Reporter Latin America, Dr Alejandro López Osornio, director of Information Systems in Argentina’s Ministry of Health says “The challenge is to balance the need to share information while respecting privacy and autonomy of people who generate it.” 

    There’s been progress, and more to do. The next steps are in the National Digital Health Strategy, The goal’s to consider both patients’ rights to share information only with their healthcare professionals and simultaneously respect provinces’ and private institutions’ autonomy to develop their information systems and share data with other authorised users and organisations when necessary.

    Argentina invested in a minimum national infrastructure that integrates and connects all the countries current projects. Anyone working with health information system in different jurisdictions can communicate centrally and automatically with all other authorized participants.

    There are several outcomes. Everyone speaks the same information language and shares the same type of information safely and privately. Healthcare quality’s improved. Patient empowerment’s the core component of strategy and planning.

    Patients can use smartphone apps to record dietary information and their exercise activities. It’s expected that app providers will soon help patients to understand their clinical and health data better. Examples are their cholesterol trends and comparing their weight. This information can help them make important health and life-style decisions.

    Argentina modelled its eHealth strategy on Canada’s It reflects its federal institutions and independent provinces. Local eHealth fine-tuning’s still needed. Human eHealth capacity’s a critical difference between the countries. One Hundred Leaders was Argentina’s strategic response. It plans to train one hundred computer scientists or doctors in this field, four for each province. The National Digital Health Strategy provides for scholarships for a postgraduate course of four to six months, mostly online, to provide local specialists and avoid medical staff having to the Ministry of Health in Buenos Aires for advice. This’s an initiative relevant for Africa’s eHealth strategies.

    The next strategic phase’s being developed. A scenario is to enhance eHealth regulation and integrate different strands, such as digital signatures, electronic documents and privacy and security of documents, into a single law. Existing personal data protection and digital signature laws can be extended to health and its EMR repositories. A general digital health law is an option.

    Argentina’s rapid progress and future strategy offers a constructive comparator for Africa’s health systems. Both technology and human eHealth capacity are moving ahead together. While it’s challenging, it’s essential to maximise eHealth’s benefits.

  • Planning, stumbling blocks and learning: Argentina’s advancing health centre eHealth programme

    While considerable challenges remain, Argentina’s eHealth revolution’s gaining ground.

    A report in eHealth Reporter Latin America says it’s the view from the Argentine Association of Users of Information Technology and Telecommunications, (USAIRA) at its 8th Forum of IT Health Argentina  at the National Academy of Medicine in Buenos Aires 

    Dr Daniel Rizzato Lede, Director of Development of Healthcare Information Systems at the Ministry of Health, described how the Argentinian National Digital Health Strategy will promote connectivity between different health centres and develop a dialogue between information systems in provinces. It’s part of a digital strategy for Ministry of Universal Health Coverage (CUS) project that connects 14 provinces and a unique EMR for all patients, regardless of local government, medical institution or facility. 

    Defining national eHealth standards is planned before the end of 2019. It’ll enable implementation of a national eHealth infrastructure with scalable projects in provinces that operate within regulatory and legal frameworks. Before 2023, these services will be in all Argentinian provinces. 

    Guidelines for a strategy for a paper-free environment are underway at the Hospital de Alta Complejidad en Red “El Cruce”, Buenos Aires. Matías Said, functional analyst and project coordinator says it’ll be in place in the 180-bed hospital before 2022. 

    The In addition, , from Swiss Medical Group (SMG) has a long-term project for a unique health information system that integrates management of 30 health care units. It began in 2014. Daniel Castro said it involves 11,000 doctors and dentists, 1,500 nurses, 1,200 administrative employees, 300 telemarketers and 1,700 assistants.

    Gonzalo Rojo, a pediatrician, shared the step by step EMR implementation in the Hospital Britanico de Buenos Aires. The project started from scratch in August 2016. There are 80 project team members, and 200 direct collaborators. Doctors are on the hospital group leading the initiative. His crucial insight that’s a lesson for all eHealth project’s is that “Sometimes, we lose sight how easy it is for the doctor to use paper.” 

    Other contributors included the collaborations between RedHat and the Massachusetts Open Cloud (MOC). Its aim’s to increase processing imaging speeds and diagnostics precision. OMINT in Brazil, presented research into chatbots. They show that only 16% of 1,700 calls required the intervention by a human operator. Some 95% os users registered satisfactory responses.  Here come the robots.

  • 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.