• mHealth
  • WHO digital health guideline: 7. Decision support for health workers

    Decision support is the topic of the seventh part of the WHO Guideline on Digital Interventions for Health Systems Strengthening. Key points are summarised below.

    The main WHO recommendation: the use of health worker decision support via mobile devices in the context of tasks that are already defined as within the scope of practice for these health workers.

    Electronic decision support systems help health workers to make better decisions, using available patient data to generate patient-specific assessments or recommendations for the clinician to consider. In many countries, where quality of care is suboptimal, decision support tools can offer guidance to health workers and help to improve adherence to recommended clinical practices.

    Decision support tools can support numerous clinical interactions, including diagnosis, treatment and referrals, to minimize errors and improve care. They use various techniques, including algorithms and rules based on clinical protocols, to create case management checklists and to assist with activity planning and scheduling. Over the last decade, they have progressed to mobile devices, providing unique opportunities for point-of-care assessment, diagnosis and management.

    For community health workers, effectiveness evidence suggests that these tools may have positive effects on their support for patients taking prescribed medication, though may make little or no difference to the clients’ overall health status and their satisfaction with the information they receive.

    Qualitative evidence suggests that health workers find decision support tools useful and reassuring for guiding the delivery of care. However, some health workers perceive algorithms as too prescriptive, and are concerned that they may lose their clinical competencies by blindly following treatment algorithms.

    Health workers are advised to explain to patients that they will use a digital device and seek clients’ permission first, to help ensure that use of the device does not impact negatively on the relationship with the patient.

    While health workers based in peripheral facilities and rural communities may find these interventions particularly helpful, they are also exposed to obstacles such as less access to electricity and network coverage. Challenges related to network connectivity, access to electricity, usability of the device, and sustaining training and support are noted.

    There is extensive additional discussion in the Guideline. Pertinent comments include that the validity of underlying algorithms and decision-logics must be carefully considered and that decision support tools should not be used for tasks that are beyond the health workers’ current scope of practices.

    My next piece in this eHNA series deals with digital tracking of clients’ health status and services.

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    The WHO Guideline provides evidence-based recommendations of ways to use digital health to improve health services. It has a specific focus on mobile devices and emerges out of guidelines on digital health interventions for RMNCAH developed by this team.

    Topics are:

    Acceptability and feasibility findings Birth and death notification via mobile devicesStock notification and commodity management with mobile devicesClient-to-provider telemedicineProvider-to-provider telemedicineTargeted client communication for behaviour change Health worker decision supportDigital tracking of clients’ health status and services Training and education via mobile devices

    Evidence is presented under headings of:

    EffectivenessAcceptabilityFeasibilityResource useGender, equity and human rights.

    Implementation considerations address key topics from the WHO/ITU National eHealth strategy toolkit, such as:

    Legislation, policy and complianceInteroperability and standardsWorkforce.

    Explore more eHNA coverage of WHO initiatives here.

  • WHO digital health guideline: 6. Targeted client communication for behaviour change

    The sixth part of the WHO Guideline on Digital Interventions for Health Systems Strengthening deals with targeted communication.

    WHO recommends targeted client communication via mobile devices for behaviour change regarding sexual, reproductive, maternal, newborn and child health, under the condition that concerns about sensitive content and data privacy are adequately addressed.

    The idea of sending health messages to help people find care, or to retain them in care, has been around for some time. Digital channels allow progressively more precise targeting of those messages, based on a person’s health status or demographic profile. Channels include text messaging, voice, interactive voice response, multimedia and gamified apps on mobile devices, social media.

    Targeted communication appeared in two previous communicable disease guidelines. The 2016 guidelines on the use of antiretroviral drugsinclude a recommendation on the use of text messaging to support adherence to antiretroviral therapy; and the 2017 guidelines for treatment of drug-susceptible tuberculosis and patient care recommend the use of text messages and voice calls to support health education and treatment adherence.

    Effectiveness evidence evaluated for the Digital Interventions Guideline revealed the following.

    1. There may be positive impacts on some behaviours and health outcomes for:

    Oral contraception use by adolescentsModern contraception use by adultsAdherence to antiretroviral medicationsAttendance of antenatal care appointmentsTaking iron and folate tablets during pregnancySkilled birth attendanceReceipt of childhood vaccinationsAttendance of HIV appointments among exposed children.

    2. There may be little or no difference to:

    Health status as assessed by CD4 count Adherence to prenatal antiretroviral medication.

    3. Very low certainty of evidence for:

    Adherence to antiretroviral medicationAttendance for STI/HIV testing among adolescentsBreast and cervical cancer screeningWomen’s attendance for neonatal appointments.

    4. There may be some unintended negative consequences, such as women experiencing physical violence in the context of receiving targeted communications for sexual and reproductive health services.

    Evidence suggests that targeted communication is generally acceptable to individuals, creating feelings of support and connectedness. Nevertheless, some have concerns about the confidentiality of health information, particularly those with HIV infection and other aspects of sexual reproductive health, and may be difficult for people with low literacy, or limited or controlled access to mobile devices.

    There is extensive additional discussion in the Guideline. Pertinent comments include that measures should be taken to address issues such as mobile device access inequities and concerns about sensitive content and data privacy. Attention is also needed to implement adequate consenting procedures, ensuring that clients are aware of how to opt out of receiving the communication. Issues around policy, infrastructure and sociocultural considerations are discussed too.

    My next piece in this eHNA series will summarise recommendations on health worker decision support.

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    The WHO Guideline provides evidence-based recommendations of ways to use digital health to improve health services. It has a specific focus on mobile devices and emerges out of guidelines on digital health interventions for RMNCAH developed by this team.

    Topics are:

    Acceptability and feasibility findings Birth and death notification via mobile devicesStock notification and commodity management with mobile devicesClient-to-provider telemedicineProvider-to-provider telemedicineTargeted client communication for behaviour change Health worker decision supportDigital tracking of clients’ health status and services Training and education via mobile devices

    Evidence is presented under headings of:

    EffectivenessAcceptabilityFeasibilityResource useGender, equity and human rights.

    Implementation considerations address key topics from the WHO/ITU National eHealth strategy toolkit, such as:

    Legislation, policy and complianceInteroperability and standardsWorkforce.

    Explore more eHNA coverage of WHO initiatives here.

  • Is a freemium model the way to go for eHealth apps?

    The proliferation of medical apps for disease prevention and health promotion has made healthcare ever more accessible. It is further facilitated by the ubiquity of smart phones and demand for better healthcare.  

    The number of digital health apps available in the market has reached over 300,000 apps on the top app stores worldwide, almost double the number available in 2015. Over 200 apps are added daily.  

    Sadly, many of these apps aren’t sustainable for more than a year, fail due to a number of reasons, including poorly structured revenue models.  A number of the businesses I evaluated during my master’s research relied on fragmented funding from various sources such as donor organisations to support development of their products.  When this funding is depleted, other revenue models need to be put in place to ensure sustainability. 

    Freemium is a popular model in which the basic application is free for users to download and use for as long as they like, though enhanced functionality is available at a price. Eventually, some of these satisfied, non-paying users will want to upgrade to a better version of the app or make in-app purchases, and hence become paying customers.

    In order to generate revenue from freemium apps, these three attributes need to be fulfilled;

    Capture high market share - the market strategy needs to revolve around capturing as much of the market share as possible because only a small percentage will become paying consumers and support the cost of non-paying users.Have a strong competitive advantage - the free offering must fulfil a need for the user in order to create a positive buzz, and the paid version has to create added value for customers to induce them to upgrade.Continued value creation - the freemium product should continue to add value as the user uses it over time in order to encourage non-paying users to switch over, and to maintain a consistent base of paying users.

    This model works well for innovations that are highly adaptive and iterative. Motivation to become a paying consumer relies on the value that the product adds for the user.  As soon as the value diminishes, interest in using the app wanes as well. The challenge for these companies becomes staying ahead of a rapidly evolving and innovative industry.

  • WHO digital health guideline: 2. Birth and death notification with mobile devices

    A global effort is underway to strengthen Civil Registration and Vital Statistics (CRVS). Its ambitious goal is to achieve “universal civil registration of births, deaths and other vital events, including cause of death, and access to legal proof of registration for all individuals by 2030”. It’s led by World Bank and WHO.

    The guideline confirms that there is limited evidence on the effectiveness of using mobile devices for birth notification and no evidence of its effectiveness for death notification. It summarises qualitative data that suggest some acceptability, feasibility and equity issues that arise when using mobile phones for CRVS.

    The specific recommendations provided in the guide include an advisory that they only be applied after rigorous assessment of specific contexts and conditions. A number of other legal, workforce, infrastructure and ethical considerations are also discussed.

    WHO recommends the use of birth notification via mobile devices under these conditions:

    In settings where the notifications provide individual-level data to the health system and/or a civil registration and vital statistics (CRVS) systemThe health system and/or CRVS system has the capacity to respond to the notifications.

    WHO recommends the use of death notification via mobile devices under these conditions:

    In the context of rigorous researchIn settings where the notifications provide individual-level data to the health system and/or a CRVS systemThe health system and/or CRVS system has the capacity to respond to the notifications.

    The guideline development group (GDG) acknowledged that despite evidence limitations, the following potential advantages justify consideration of mobile notifications, after careful due diligence. The GDG notes that:

    Birth notification represents a vital first step in a care cascade that can ultimately lead to increased and timely access to health services and other social services, though birth notification should not be viewed as a substitute for legal birth registrationDeath notification Is recommended via mobile devices in the context of rigorous research and where notifications can be linked to health and/or CRVS systems, to address the lack of information on deaths, especially deaths outside of facilities.

    These CRVS recommendations and cautionary notes emphasise the complexities of digital health and the critical importance of understanding human contexts before promoting the use of mobile devices. African countries, which have numerous mobile health initiatives already underway, will find the discussion of this guidelines chapter useful to carefully consider mobile approaches to CRVS.

    This is the second piece in an eHNA series on the WHO guideline Recommendations on Digital Interventions for Health Systems Strengthening. The previous one was about acceptability and feasibility. The next one will unpack the third guideline chapter on stock notification and commodity management via mobiles.

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    The Guideline provides evidence-based recommendations for ways to use digital health to improve health services. It has a specific focus on mobile devices and emerges out of guidelines on digital health interventions for RMNCAH developed by this team.

    You can find more eHNA coverage of WHO initiatives here.

  • WHO digital health guideline: 1. acceptability and feasibility

    This is the first piece in an eHNA series to unpack the WHO Guideline Recommendations on Digital Interventions for Health Systems Strengthening. The perspectives are relevant to digital health in African countries, where digital health is becoming a key driver of our health systems transformation.

    The chapter on acceptability and feasibility begins by describing factors that increase digital health acceptability for health workers, such as to:

    Help health workers to be more efficientSave travelling time, allowing health workers to spend more time with their clients or to provide more services, remotely to clients in rural areasAllow health workers to expand their range of tasks and take on tasks previously assigned to higher-level workers.

    It suggests that some health workers appreciate how digital technologies:

    Improve flexibility to work when convenient Reduce the need to be office-bound to access informationImprove coordination by connecting people, including clients and communities Raise health workers’ social status and increase the trust and respect they receive in communities.

    The guideline also recognises that digital health can be a double-edged sword, and some factors may decrease acceptability. It points out that some health workers may:

    Experience workload increases due by technological interventionsFace data costs that are not covered by the employerBe anxious about carrying multiple devices and fear loss, damage or theft of the devicesFear job security risks if they have poor digital literacy.

    The authors list factors that affected the feasibility for health workers to take up digital health opportunities, such as:

    Network connectivity and access to electricity to charge their mobile phones Usability of digital devices and integration with other digital systemsUser interface issues, particularly around language and utility of the interface for capturing and retrieving dataThe extent to which confidentiality of medical information and data security issues are addressedChange management issues such as training and familiarity with digital technologies to help support users Supportive supervision to build confidence in new approachesHealth workers’ perception about whether tracking and monitoring, which makes their work more visible, is positive or negativeThe extent to which health workers’ efforts are limited by broader health systems challenges, such as underlying medical supplies shortages that reduce health system effectiveness regardless of digital health interventions.

    Since clients are often active participants in digital interventions, the guideline describes factors that may influence their acceptance of digital health. This includes that:

    Some clients appreciate the fact that someone is taking the time to send them messages, appreciating the support, guidance and information, reassurance and motivation.Individuals who are dealing with health conditions that are personal or stigmatized, such as HIV or family planning services, may worry that their confidential health information might be disclosed if they participate in digital healthSome clients prefer face-to-face contact to telemedicine services, yet these services can also help to give individuals who speak minority languages access to health workers who speak this language Telemedicine may help clients save money and reduce the burden of travel for specialist opinionsOut of pocket expenses may be an issue where clients are charged to participate in digital health Barriers such as poor access to network services, electricity or mobile devices, low literacy or digital literacy skills need to be addressed.

    My next eHNA piece will unpack the next chapter in the guideline, birth and death notification via mobile devices.

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    The Guideline provides evidence-based recommendations of ways to use digital health to improve health services. It has a specific focus on mobile devices and emerges out of guidelines on digital health interventions for RMNCAH developed by this team.

    You can find more eHNA coverage of WHO initiatives here.

  • Competitive telemedicine platform to help achieve UHC

    AfriDOKTA is passionate about transforming the delivery of healthcare in Africa through people, processes and technology. They have developed a telemedicine mHealth platform dedicated to Sustainable Development Goal 3, “Ensuring healthy lives and promoting well-being for all at all ages”. Anyone with a smart phone or internet access can easily download the AfriDOKTA app and would have immediate access to quality outpatient care.

    The Kenyan government is the first African country that has supported the roll-out of AfriDOKTA as part of a nationwide campaign towards universal healthcare. The roll out is supported at the community level by community health workers (CHWs) that train users on how to access health services using the AfriDOKTA app. Users can easily create a personal profile and an electronic medical record to store details of consultations received. The app also gives users referrals to vetted pharmacies and labs with certified medical professionals. 

    A unique design feature of the AfriDOKTA app is that it complies with international data security standards and adheres to the US-based Health Insurance Portability and Accountability Act (HIPAA). The architecture also applies Health Level 7 (HL7), SNOMED, and DICOM standards. These are international principles used for the transfer of clinical data between various software and electronic applications.

    AfriDOKTA's use of international standards for storing, accessing, and processing medical images and related information, their plans for strategic collaboration and relevant product benefits make it a strong competitive differentiator in the market. This solid technical foundation should position the platform to support our Universal Health Coverage (UHC) aspirations too.

  • Research2Guidance publishes its eHealth connectivity report

    Working within ecosystems is increasingly important for eHealth. Research2Guidance third report of its mHealth Economics 2017/2018 program deals with connectivity. It sees mobile apps as the core of eHealth connectivity hubs. These extend connectivity to wearables, tracking sensors, medical devices, tools, access to third party aggregated health data and EHRs.

    The report is an introduction to mHealth connectivity in mobile health. It discusses the connectivity landscape too. Contents are: 

    Tool usageConnecting to health data via APIsConnecting to sensors and wearablesConnecting to API aggregatorsConnecting to electronic health recordsOutlook on the future of connected devices. 

    These provide answers questions of:

    What eHealth connectivity options exist?To what extent are eHealth publishers connecting to sensors and wearables?Which tools are mHealth app developers using?Are mHealth app developers offering Application Programming Interfaces (API) for their apps?To what extent do they use aggregated health data through APIs?Which roles do EHRs play in eHealth?How will connectivity to sensors change in the near future?

    It’ll provide a wide range of stakeholders with insights needed for mHealth strategies, plans and initiatives. As Africa’s health systems keep building on their mHealth investments, the report is helpful in moving them on.

  • An eBook sets out six steps for clinical mHealth

    Clinical teams have increasing mHealth opportunities. mHealth strategies should provide the bases for decisions to use them. An eBook by Spectralink, a communications provider, available from Health IT Security, sets out six steps. The goal’s to invest in clinical smartphones for healthcare professionals to communicate, collaborate and co-ordinate patient care across wide arrays of teams and team members. 

    Six Steps to Developing a Successful Clinical Smartphone Strategy combines generic strategic concets, such as vision, with technical components. The six steps are:

    Define an overall vision for mHealth technology initiativesUnderstand information flows, application and technology requirementsEvaluate enterprise-class smartphone solutionsAssess ICT infrastructure and requirements, including Wi-FiImplement a proof of concept and pilot programmeAddress operational issues, including training and support requirements. 

    Creating successful clinical mHealth strategies need measured, forward-thinking. Improving patient care and outcomes, and accounting for future technology advancements  must be the focus. It should include people, processes and technology to maximise organisation’s benefits.

    The eBook extends from strategy to mHealth investment. Acfee would include a step for business cases to generate and compare options to identify and estimate:

    Strategic fitSocio- economic impact, including optionsManagement capacity to deliver and realise net benefitsFinance and affordabilityCommercial themes, such as contractual options.

    Completing this would be before and after step 5. Step 6 should also address benefits realisation issues. These lay foundations for M&E as step 7. 

    Africa’s health systems assign a high priority to mHealth. The eBook provides a process that they can adopt and ehance.

  • Nigeria uses mHealth to improve blood donations

    Blood shortages are common in many health systems. An initiative in Nigeria uses mHealth to create a community of voluntary blood donors, and connects hospitals with blood banks, and blood banks with donors. Life Bank, a Lagos start-up also provides a discovery platform on for hospitals to order blood

     LifeBank delivers requested blood in less than 45 minutes, in a WHO Blood Transfusion Safety compliant cold chain. An article in Disrupt Africa says it’ll add other medical products such as oxygen, vaccines and rare drugs to its services.

    Its founder, Giwa-Tubosun, began a non-profit service to encourage people to donate blood. She then moved on to address supply shortages and poor logistics. Two main goals are: 

    Increasing access to bloodReducing the number of Nigerian women who die from birth complications. 

    LifeBank’s resources include: 

    AIBlockchainCold chainmHealthMotorbikes.

    These combine to provide information about blood availability and avoid health workers’ wasted time and frustration seeking blood products. They also minimise ineffective blood transports that result in bacteria proliferation and consequences of health complications.

     Supporters include:

    Co-Creation Hub (CcHub) in 2016 that raised pre-seed fundingEchoVC Partners, a venture capitalistParticipation in Merck’s Lagos-based satellite accelerator this yearSelection for MIT Solv2018 that added grants and access to other resources.

    Its impact is considerable. To date, LifeBank’s delivered some 11,000 products for over 400 hospitals. Over 6,300 people are registered as voluntary blood donors, with over 20% donating blood in the last two years. The result: over 2,100 lives saved.

    A challenge is convincing blood bank partners to use LifeBank. As this is  overcome, it’s it easy to envisage LifeBank eventually operating across Africa.

  • AI, blockchain, cold chain and motorbikes improve blood donations and save lives in Nigeria

    Blood shortages are common in many health systems. An initiative in Nigeria uses mHealth to create a community of voluntary blood donors, and connects hospitals with blood banks, and blood banks with donors. Life Bank, a Lagos start-up also provides a discovery platform on for hospitals to order blood

    LifeBank delivers requested blood in less than 45 minutes, in a WHO Blood Transfusion Safety compliant cold chain. An article in Disrupt Africa says it’ll add other medical products such as oxygen, vaccines and rare drugs to its services.

    Its founder, Giwa-Tubosun, began a non-profit service to encourage people to donate blood. She then moved on to address supply shortages and poor logistics. Two main goals are:

    Increasing access to bloodReducing the number of Nigerian women who die from birth complications.

    LifeBank’s resources include:

    AIBlockchainCold chainmHealthMotorbikes.

    These combine to provide information about blood availability and avoid health workers’ wasted time and frustration seeking blood products. They also minimise ineffective blood transports that result in bacteria proliferation and consequences of health complications.

    Supporters include:

    Co-Creation Hub (CcHub) in 2016 that raised pre-seed fundingEchoVC Partners, a venture capitalistParticipation in Merck’s Lagos-based satellite accelerator this yearSelection for MIT Solv2018 that added grants and access to other resources.

    Its impact is considerable. To date, LifeBank’s delivered some 11,000 products for over 400 hospitals. Over 6,300 people are registered as voluntary blood donors, with over 20% donating blood in the last two years. The result: over 2,100 lives saved.

    A challenge is convincing blood bank partners to use LifeBank. As this is  overcome, it’s it easy to envisage LifeBank eventually operating across Africa.