Tom Jones

eHealth strategist, planner and evaluator

  • Kenya’s mHealth standards sets out legal and ethical rules

    All eHealth has legal and ethical implications. Kenya Standards and Guidelines for mHealth Systems sets out the Ministry of Health approach. A core component is responsibility to protect data stored on mobile devices from unauthorised access. It proposes two authorisation levels.

    The standards make it explicit that mHealth developers must comply with Kenya’s laws. It requires that data is:

    • Obtained and processed fairly and accurately
    • Only collected for specified and legitimate purposes
    • Not used inappropriately
    • Only stored for as long as it’s needed
    • Recorded appropriately and proportionately
    • Accurate.

    Standards for using mHealth data and devices include:

    • Ownership
    • Access and disclosure
    • Storage required within Kenya’s jurisdiction without formal authorisation
    • Maintain confidentiality when used for diagnoses and prescriptions
    • Comply with data protection and other technology legislation and regulation
    • Comply with intellectual property rights.

    Kenya’s mHealth must also comply with WHO guidelines. These add to Kenya’s strict regulatory code. It offers a standard for all Africa’s eHealth.

  • All-Wi-Fi standard has a cyber-security vulnerability

    A serious weakness’s been found in Wi-Fi networks.  Mathy Vanhoef of imec-DistriNet at KU Leuven found it. The paper on Krackattacks says WPA2, a security protocol, can be exploited by cyber-criminals using key reinstallation attacks (KRACK) within victims’ range. Once in, they can read information assumed to be encrypted, and steal sensitive information such as credit card numbers, passwords, chat messages, emails and photos.

    Attack succeed against all modern protected Wi-Fi networks. Depending on the network configuration, data can be injected and manipulated. Ransomware and other malware could find its way to websites.

    Weaknesses are in the Wi-Fi standard itself, not in individual products or implementations. Any correct WPA2 implementation is likely to be affected. Prevention needs users to update affected products when security updates are. If a device supports Wi-Fi, it’s probably affected.

    Vanhoef’s initial research found that Android, Linux, Apple, Windows, OpenBSD, MediaTek and Linksys are affected by variants of attacks. A proof-of-concept executed a key reinstallation attack against an Android smartphone. Attackers could easily decrypt all data transmitted by victims because the key reinstallation attack’s exceptionally devastating against Linux and Android 6.0 or higher. These can be tricked into reinstalling an all-zero encryption key.

    While attacking other devices finds it harder to decrypt all packets, large numbers of packets can be decrypted. A demonstration in Vanhef’s paper shows the type of information that a cyber- attacker can access using key reinstallation attacks.

    Africa’s eHealth programmes need to seek and install patches and updates from their vendors. The findings show, yet again, a cyber-world full of holes, many of which may still be unidentified. Constant vigilance is essential. As participants at Acfee’s recent eHealthAFRO 2017 said, cyber-security is everyone’s business.  

  • Gates Foundation highlights Africa's challenges

    This year’s annual report from the Gates Foundation sets a clear, optimistic tone with a practical view ahead.

    “Fewer people than ever before contracted polio, and more women had access to contraceptives than at any other time in history. We supported the fight against Zika virus. And this was the year that almost $13 billion was raised to support the Global Fund's mission to accelerate the end of AIDS, tuberculosis and malaria as epidemics. While we are deeply proud of this progress - and all that we have achieved together so far - we remain mindful of the great challenges that lie ahead.”

    The Economist has extracted from the report a gloomy side for Africa. Its commentaries include:

    • Campaigns to eradicate extreme poverty, HIV and malaria are going awry
    • Demography’s one of the biggest reasons for gloom
    • An enormous fertility gap’s opened between benighted places and everywhere else
    • High birth rates lead to high dependency ratios where relatively small adult populations support lots of children
    • The fertility gap between Africa and the rest of the world’s set to close very slowly, taking 40 years to drop from five to under three
    • Africa’s population of over 1.2 billion will be 2 billion by 2046 and 3 billion in 2071
    • By 2030, there’ll be over 280 million 15 to 24 year olds, over 20% of the current population
    • Fewer Africans living in deep poverty but the slow reductions leave about 415 million people, about a third, and are outstripped by population growth
    • About 50% of the world’s poor are thought to be in Africa
    • Future funding for HIV, malaria and Neglected Tropical Diseases (NTD) such as lymphatic filariasis that can lead to expanded body parts, river blindness and sleeping sickness, is uncertain
    • Vaccine-resistant malaria could evolve and spread
    • A risk of AIDS increasing despite objective such as AIDS free generation
    • Better HIV survival rates means more expensive and expanding treatment and costs, possibly leading to inadequacies and more cases
    • Health spending in 32% of sub-Saharan African countries, about 17, is less than 3% of their GDP, less than the 5% seen as a minimum for the basics.

    The Gates report says the biggest risk to progress is failing to control infectious disease. The impact in Africa of more HIV and malaria will be rapid. Is this the essential focus of the next wave of Africa’s eHealth investment? With Universal Health Coverage (UHC) as a priority, it may not be enough if infectious diseases rampage across Africa.

    Should prevention and surveillance be the top priority for the next few years so eHealth can help to stabilise the substantial achievements already secured?

  • Nurses need an eHealth communication platform too

    As eHealth expands its healthcare role and impact, a significant emphasis’s on nurses’ needs for better information and communication’s essential. They comprise healthcare’s biggest professional cadre. A white paper from Spok, a global healthcare communication company, sets out a way to do it.

    CONNECT THE DOTS: NURSING 3 Ways to Enhance Workflows for Nurses With an Enterprise Healthcare Communications Platform says 54% of nurses are dissatisfied with their current communication methods outside EHRs. It can inhibit nursing evolution such as:

    • Changing healthcare
    • Taking on more responsibilities and duties
    • Expanding regulations
    • Cost pressures
    • Increasing collaboration
    • Adopting new technologies
    • Increasing complexities of their roles.

    About 54% of nurses are dissatisfied with their current communication services outside EHRs, so initiatives are needed to support them. These must be structured, with practical strategies for:

    • Care team communication
    • Patient Care co-ordination
    • Workflow efficiency.

    Spok’s solution includes eHealth that supports automated communication such as:

    • Messaging and location tracking
    • Workload assignment and management
    • Capturing patient data on mobiles and transmitting urgent requests to other nurses and healthcare professionals and their services
    • Find and link with appropriate clinicians promptly
    • Efficient patient discharge and transfer processes.

    With eHealth’s allure of better clinical standards within finite budgets, not everything can be achieved simultaneously. eHealth for better communication between healthcare professionals offers valuable healthcare quality too, so Africa’s eHealth strategies and programmes should find a place for this. It can build from its existing mHealth priorities and investment.

  • Most medics share passwords. Do you?

    A cornerstone of cyber-security’s rigorous password management. It seems it’s not very rigorous. A US study, Prevalence of Sharing Access Credentials in Electronic Medical Records in Health Informatics Research (HIR), found that almost three-quarters, almost 74%, of medical professionals have used a colleagues’ password to access EMRs. It’s partly a failing on access authorisation.

    Within this group, 100% of medical residents say they’ve done it. About 83% of interns and 77% of students said they used someone else’s password because they were not given a user account. About 57% of nurses say they’ve done it. 

    The average number of times that each person shared passwords was 4.75.  While this is alarming, many of the reasons for the practices reveal password regimes that don’t match medical professionals’ roles in patient care.  

    There are two big causes of the practice. One is where passwords are not assigned to professionals who need it. The other is where access authorisation is insufficient for professionals to fulfil their roles. It also seems that access authorisation may not be extensive enough, with some professionals having no passwords.

    The study concluded that password use’s doomed because medical staff share their passwords. It sees strict regulations requiring each professional to have a unique user ID might lead to password sharing, leading to reduced data safety. 

    Another perspective may be that eHealth’s access control needs overhauling to match professional’s working practices more closely. Three recommendations from the study for healthcare organisations are:

    •  Make it easier and less time-consuming to have access credentials
    • Delegate administrative tasks and extend EMR access to para-medical, junior staff, interns and students in understaffed hospitals, especially during on-call hours
    • Allow maximum privileges for one-time use only, so junior staff can access records under urgent, lifesaving conditions without having to use someone else’s password.

    These need IT teams to be more responsive. It seems inevitable to ensure data security and integrity. As Africa move further towards EHRs, these practices could be incorporated from the outset.   

  • England’s mHealth has successes and challenges for African initiatives to learn from

    Strategies and plans for mHealth and mobile working stretch across most of Africa. A service from Digital Health can help the continent’s health systems to compare their performance with some of England’s NHS mHealth initiatives. Its Advisory Series, August 2017 deals with mobile and modern working. It has two perspectives, projects for clinical staff working in communities and mHealth that improves hospital care and to help non-clinical staff to be efficient.

    For mental health services, a goal’s to extend mobile access to EHRs for staff working mainly outside hospital. It includes logistics data such as patients’ locations and travel plans between them. mHealth benefits inpatient services too, where there are many routine tasks, such as therapeutic observations, and not similar to some community services that can involve complicated conversations that need recording. An mHealth solution from an in-house development enables health workers to use a range of phones or tablets that provide process-driven interfaces about patient care. mHealth can also replace traditional paper ward diaries with eLogistic  systems.

    Clinical audit and research can benefit from mHealth. An app can capture data about interactions with patients and match these against clinical guideline milestones. Instead of writing activities, doctors can tick boxes and data can be analysed and practices reviewed. Time saving and better quality healthcare are the results.

    South Gloucestershire Clinical Commissioning Group is another organisation which has found increased efficiency through greater use of mobile – simply by introducing the sort of electronic diary management abilities most take for granted in their private lives.

    Bring Your Own Device (BYOD) isn’t seen as viable for some NHS organisations. The extra complexities it brings can disrupt and a number of cultural changes to clinical and working practices are needed to realise mHealth’s benefits. These are the most challenging components of mHealth projects. They’re more significant than affordability challenges of devices, software, licences, connectivity and cyber-security. Mind-set changes and clinical leadership are essential for success. Clinical informatics champions, currently a small cadre, are helping to increase mHealth adoption.

    Africa’s mHealth programmes will have encountered many of these themes. There’s strong case for their leaders to share their experiences too.

  • Africa’s eHealth needs more emphasis on developing and integrating PHC

    Effective, accessible primary healthcare’s (PHC) essential to improving population health. The World Bank aims to help by improving and sharing knowledge. Its project Strengthening Primary Health Care for Results supports Maternal, Neonatal and Child Health (MNCH) services, and conforms two of the Bank’s Country Assistance Strategy (CAS) to: 

    • Strengthen human capital and safety nets, so access to, and quality of, health services
    • Promote accountability.

    It’s also a partner with the Gates Foundation and WHO in the Primary Health Care Performance Initiative (PHCPI), a project recognising PHC as a weak link in most health systems. The objective’s to support countries to strengthen monitoring, tracking and sharing key PHC performance indicators. PHCPI partners highlighted the far-reaching benefits of stronger primary health care .

    The Economist has two examples of these. Brazil and Costa Rica have better healthcare systems than other countries with similar incomes. One reason’s their extensive network of trained PHC workers. Costa Rica PHC doctors and nurses provide 75% of consultation. The country’s third for highest life expectancy in the Americas.

    The two countries GDP per head is between US$ Purchasing Power Parity (PPP)15,000 to 17,000. Six African countries match or exceed the range. It seems more challenging for the other 48. eHealth programmes that help to create, develop support and expand PHC services are priorities for progress.  

    A study in PLOS suggested integrating Informal Healthcare Providers (IHP) may be part of the solution too. What Is the Role of Informal Healthcare Providers in Developing Countries? A Systematic Review used 122 studies, 48% from sub-Saharan Africa to identify large-scale reliance on IHP services.  Globally, they range from 51% to 96% of healthcare providers. Utilisation ranges from 9% to 90%.

    Studies also found poor adherence by IHPs to countries’ clinical guidelines. People rely on them because they’re convenient, affordable and for social and cultural effects. They also offer flexible working hours, sometimes open all hours, more likely to have medicines in stock, closer and provide more rapid services.

    Recommendations from the studies include:

    • IHP education, including capacity building and training programmes
    • Oversight, including regulation, enforcement and registration
    • Better processes, including collaboration and engagement
    • Recognising IHPs’ social and cultural value
    • Reducing the need for IHPs by improving access to formal providers.

    If these are acceptable to Africa’s health systems, integrated eHealth programmes should extend to IHPs. These could include clinical support and eLearning. It also needs wide-ranging stakeholder engagement and to be part of a sophisticated healthcare transformation project, so effective political, clinical and executive leadership.

  • Drones can measure some vital signs

    Using drones in healthcare’s taking a step from supplies delivery to a clinical role. Two PhD students, Ali Al-Naji and Asanka Perera, at the University of South Australia (UniSA) have used drones to measure heart and breathing rates remotely and accurately. They used advanced image-processing systems and created an algorithm

    The initiative grew out of a desire to find a non-contact sensor to replace electrodes used in developing countries to detect vital signs in new-born babies. It can help to reduce infections. Other uses can be in:

    • Nursing homes
    • Areas prone to human infection, such as neonatal wards
    • War zones
    • Isolated communities
    • Car accidents
    • Sea rescues
    • Natural disasters.

    A report in BioMedical Engineering Online says the drones detected vital signs in 15 healthy people aged between two and 40 over three years. It can do this simultaneously, and while people are moving.

    Sensory Systems Prof Javaan Chahl at UniSA, the project supervisor, told the The Lead, a South Australia news outlet, that the system detects movements in people’s faces and necks to detect heart and breathing rates. Drones in the trials measured the vital signs from three metres. They can also operate further away.

    With an emphasis on developing countries, the drone initiative offers Africa and new way to measure heart and breathing rates effectively and efficiently. It’s a paradigm shift from current methods.

  • Four vital insights from eHealthAFRO 2017 day one

    Day one of eHealth AFRO 2017 dealt with regional and country eHealth strategies affecting UHC in African countries. Four important insights were offered: two are from Southern Africa, one from East Africa and one from West Africa.

    Mbulelo Cabuko, Director of Health Information at South Africa’s National Department of Health (NDOH) proposed that Africa should develop its own measurements of eHealth progress that provides more depth than WHO and the Global eHealth Observatory (GOE) can provide with the limitations of its eHealth surveys. These are constrained by the need to collect comparable global data. Africa needs to be able to delve into more detail. It also needs to understand its countries’ eHealth trends and trajectories. Developing this type of survey’s demanding, but it’s needed.

    Daniel Morenzi, East African Communities’ eHealth lead, described its regional ID project. Each citizen will have a Unique Personal Identifier (UPI), including biometric data. It’ll be used to access healthcare too. Eventually, with its integrated economies, each person’s UPI will be accepted by all six EAC members for education, migration, financial and health services. Three EAC countries are piloting the initiative, Kenya, Rwanda and Uganda.

    Brigadier General (Retired) Dr Gerald Gwinji, Zimbabwe’s Permanent Secretary of Health, outlined his country’s philosophy that it must not fall behind in the expanding ICT world. eHealth’s seen as cost effective and supporting all six of the WHO pillars of healthcare strengthening:

    • Service delivery
    • Health workforce
    • Health information systems
    • Access to essential medicines
    • Financing
    • Leadership and governance.

    Dr Anthony Nsiah-Asare, Director General, Ghana Health Service, outlined core themes of his country’s NHI model. Operating since 2003, the NHI is overseen by the National Health Insurance Authority. Part of healthcare finance is raised by a 0.5% addition to the VAT rate. As healthcare demand rises, it’s suggested that this increases to 1.5%. Reimbursing hospital services relies on the Ghana Diagnosis Related Groups (GDRG). This requires a set of eHealth investments related to costing models.

    These four themes are only some of the insights shared on the first day of eHealthAFRO 2017. More will follow on eHNA and the live twitter feed @eHA2017.

  • How can Africa innovate with Unique Patient Identifiers?

    Unique Patient Identifiers (UPI) are both essential and demanding to achieve. They’re harder to use when data’s transferred and shared between organisations. An article from the American Health Information Management Association (AHIMA) proposes innovation with UPIs propriety to vendors and customers as part of the solution. For African health systems, it may improve the current position until national UPIs are in place.

    US provider organisations and payers are innovating with propriety UPIs. A common theme’s dealing with real time or batch queries held by third parties, such as credit agencies. These already have UPIs for their commercial activities. It suggests they offer value to health organisations because commercial entities frequently update and constantly maintain their data, providing current demographics for data warehouses, population health management and illness prevention.

    UPI innovation must be integrated with eHealth governance, which need developing in African health systems. Through eHealth governance, UPI innovation can engage with stakeholders such as:

    • Governance teams
    • Professional bodies
    • Patient access and registration staff
    • Health information management teams
    • ICT teams
    • Data users, such as care coordinators and health analytics teams.

    Their roles can extend to strategic information governance and how innovation and success will be applied. Mitigating risks is another role they can participate in.

    A set of generic questions can help to define UPI innovation:

    • Who’s responsible for identifiers’ integrity, especially new identifier created by innovation?
    • When existing data’s augmented with new external data, how is the new data integrated, and what is its lifecycle of managed?
    • What are acceptable uses for the identifiers set by legal and regulatory requirements for UPIs, privacy and compliance?
    • How can organisations incorporate UPI technology with human data stewardship to ensure a compliance and governance?
    • How are discussions and findings from UPI innovation relayed to eHealth governance?
    • How can discussions be for ICT, and people and process supporting eHealth governance?
    • Should innovation deal with data creation for patient access or registration, data governance through procedures, processes and data fields standardisation, or both?
    • How can a sample database be built to support proof of concept and technology?
    • How can enough data be included in UPI innovation projects for rigorous, reliable testing, such as 100,000 records?
    • How can UPI data goals be integrated into data governance programmes?

    AHIMA’s article says organisations and healthcare professionals are cautious in applying innovation to the long-standing UPI challenge. Mismatching records can have profound, adverse effects, so reluctance is reasonable. Despite these anxieties, innovation can still proceed, provided it’s based on a rigorous risk assessment, impact probability, costs and benefits.

    UPI innovation creates two activities for Africa’s health systems. One’s setting up their UPIs. The other is constant, managed innovation with UPIs.