Tom Jones

eHealth strategist, planner and evaluator

  • There’s a template for developing mHealth strategies

    With Africa’s score on the WHO results from its global eHealth survey approaching 60%, there’s still plenty to do. A survey by Spok offers some good practices for the next steps. The start point’s that there isn’t a single definition. Instead, organisations have different interpretations. Common purposes seem to be:

    • Align mobile objectives with organisational goals
    • Feed the framework for all mHealth projects
    • Answer questions such as:

    o   How can mHealth enhance patient care

    o   What strategic initiatives need including in plans for mobile enablement, such as shorter ED and inpatient discharge processes

    o   What integrations are needed meet the larger goals of the hospital, such as easier communication between healthcare teams

    o   How can mHealth improve health workers’ productivity.

    As mobile technology and opportunities develop, healthcare’s mHealth strategies need to move on to match. This needs regularly updated policies. US experience is that mHealth strategies are quite fluid, with organisations amending them as needed:

    Shifting end users’ mobile needs


    New devices available


    New EHR provider capabilities


    Changed strategic goals


    Challenging strategy implementation


    Leadership changes


    Mobility strategy not updated


    A common feature’s that stated strategic goals aren’t embedded sufficiently or explicitly enough in mHealth strategic goals. Examples are:

    • Communications between doctors
    • Nurse to doctor communications
    • Communications between nurses
    • Code team or rapid response team communications
    • Communication with health systems’ doctors networks and and other health professionals
    • Managing critical test results
    • Nurse call and patient monitoring alerts to mobile devices
    • Patient satisfaction scores
    • Patient throughput
    • ED and bed turnover
    • Alarm fatigue.

     Improving on these needs a range of engaged stakeholders. They include ICT, clinical leaders, telecommunication experts, all appropriate healthcare professionals and other health workers and the organisations’ executives. Setting them up as permanent mHealth strategy teams is a priority for Africa’s health systems.

  • Semantics aren’t good enough on pagers

    Effective communication between people and information systems in eHealth relies on rigorous informatics such as semantic Interoperability (IOp) and data definitions. A US study of pagers’ messages content reported in the Journal of the American Medical Association (JAMA) Internal Medicine found limitations of both quality and safety. These points to initiatives that Africa’s health systems can set up.

    Even with the seemingly ubiquitous mobile communication technology, inpatient healthcare teams often use pagers to communicate using text. The study team say it’s inefficient, disruptive and has communication concerns. The study analysed the content of 575 text messages on pagers in an internal medicine service of an academic tertiary care hospital. The texts included messages sent or received by physicians, nurses, students and ancillary staff. They included texts about the care of 217 patients. 

    Most messages, 78%, were sent to doctors by healthcare workers who were not doctors. The analysis revealed three main deficiencies:

    • No standardisation, including information on vital signs
    • Unclear vocabulary on ranges of urgency
    • Communication gaps arising from messaging practices.

    While the ranges of content and topics were quite narrow, the team saw wide variations in message clarity and structures. It’s possible that the limitations could reduce patient safety and other aspects of healthcare quality.

    A solution’s to develop guidelines for using text paging effectively, to ensure efficient communication among health care teams. They should extend across standardised, structured communication for high-frequency topics and structured urgency flags for text paging doctors. Africa’s health systems can start their own improvement projects as part of their IOp and data dictionary projects.  While the study dealt with pagers, are the findings likely to be replicated for text messages using mobile phones?

  • Health websites need to show their providences

    As the Internet’s used more by people wanting information about their health and illnesses, it’s essential that they can see and know the reliability and constraints of the sources. A study by a UK team in the Journal of Medical Internet Research (JMIR) says the wide range of sources of health information on websites from different organisations and people need to enable users to evaluate and select the sources they want to use. They should be able to use this to assess the sites’ credibility and trustworthiness. The findings provide important information for Africa’s health systems in developing their health websites. 

    The team reviewed four multi-disciplinary and four health-oriented databases described in empirical studies on both trust and credibility and identified factors that affect judgments on both. It also analysed demographic factors affecting trust. This helped to identify gaps in current knowledge and construct proposals for future research.

    Data from 3,754 unique records were allocated to one of three categories:

    • Using trust or credibility as a dependent variable
    • Using trust or credibility as an independent variable
    • Studies of the demographic factors that influence the role of trust or credibility for health websites.

    Findings were:

    • Website design, clear layout, interactive features, and the authority of the owner provide a positive effect on trust or credibility
    • Advertising has a negative effect
    • On content, authors’ authority, ease of use and content have a positive effect on trust or credibility
    • Age, gender, and perceived health status are demographic factors influencing trust.

    More research’s needed on the interaction between variables associated with health information seeking, increased consistency of trust and credibility measurement and more emphasis on specific health website sources. The effect of demographic variables and how the enhance understanding of the impact on trust and credibility judgments need more research too. There’s no need for Africa’s health systems to wait for these before using the first set of research findings.

  • ASEAN shows how sharing data can help fight dengue

    Every 15 June since 2010, the Association of Southeast Asian Nations (ASEAN) denotes it as Dengue Day. It’s concept’s to:

    • Increase public awareness of the disease, the most rapidly-spreading mosquito-borne viral disease globally
    • Mobilise resources for its prevention and control
    • Demonstrate ASEAN’s commitment to tackle the disease.

    ASEAN’s E-Health Bulletin Special Edition The ASEAN Dengue Day: sustaining the united fight against dengue provides updates from ASEAN’s Member States on their dengue situations, national prevention and control programmes, challenges and priorities. Reports from each Member State combine into a regional profile and comparator of progress, initiatives, challenges and ideas. 

    Core themes consist of prevention and control relying on:

    •  Educating communities
    • Surveillance
    • Laboratory services.

    Laboratory-based surveillance against dengue is a vital component of combating dengue. It addresses emerging infectious diseases too, such as Zika. ASEAN’s template for sharing information and experiences in dealing with high priority diseases is a constructive template for all global regions and sub-regions to adopt.

  • Which’s best, national or regional eHealth platforms?

    India’s Union Government has a national eHospital platform. A report in The New Indian Express (NIE) says Kerala State wants its own. It’s a perspective that can be reflected in Africa’s health systems. Which approach is most appropriate?

    In Kerala, only two hospitals from Kerala - Malabar Cancer Centre in Thalassery and Vaidyaratnam P S Varier Ayurveda College Hospital in Kottakkal have enrolled in the national Online Registration System (ORS). It links hospitals across India to facilitate online appointments for patients by authenticating either through Aadhaar or a mobile number. Aadhaar provides each person with a unique, random 12-digit number issued by the Unique Identification Authority of India (UIDAI). 

    Hospitals can also use the e-Hospital platform to provide online services to patients. They include online outpatient appointments, viewing their laboratory reports and the status of blood availability in blood banks. The main objective’s to have an appointment system at government hospitals to avoid long queues that inconvenience patients when they register.

    NIE says Kerala State officers haven’t provided a precise reason for opting for its own platform. It is reported as referring to its own eHealth as state-of-the-art, implying it’s a better solution.

    The decisions raise important eHealth issues. If local eHealth’s better than a national service, why give it up. It’s not only Kerala or India where this issue surfaces. It’s been a challenge for many countries. Effective convergence strategies that build on existing good practice are excellent ideas. They’re not easy to achieve.

    Some of Africa’s health systems may face similar challenges as they move from legacy systems. Change can offer new benefits, but it can sometimes bring additional costs.

  • mHealth’s MDCS needs better cyber-security

    While mHealth’s been successful in developing countries, many initiatives fail to address security and privacy issues. Leonardo Iwaya’s at Karlstad University’s Faculty of Health, Science and Technology. His thesis, Secure and Privacy-aware Data Collection and Processing in Mobile Health Systems, starts from this perspective and describes solution. 

    He sets a context where mHealth often operates in a setting of no specific legislation for privacy and data protection in developing countries. Africa’s health systems exhibit equivalent limitations. His work has several components:

    • A comprehensive literature review of Brazil’s mHealth
    • Design of a security framework, SecourHealth, for Mobile Data Collection Systems (MDCS)
    • Design of a MDCS to improve public health using geographic Information (GeoHealth)
    • Design of Privacy Impact Assessment (PIA) template for MDCS
    • Study of ontology-based obfuscation and anonymisation functions for health data. 

    These offer Africa’s health systems a route into Information security and privacy that are paramount for high quality healthcare. They also protect healthcare professionals and other workers by creating a secure and explicit working environment for their clinical and working practices.

    Iwaya’s objective’s to enhance knowledge of the design of mHealth’s security and privacy technologies, especially the MDCS. These extend across data collection, reporting and replacing paper-based approaches for health surveys and surveillance. It’s a good place to start from to improve mHealth’s general and cyber-security.

  • Drones can be faster than conventional emergency responses

    Drones’ potential’s increasingly linked to supply chains, especially those of the big, online retailers. A report in eHNA described Rwanda’s use in delivering medical supplies. A report by Pew Charitable Trusts identified a new role coming up for drones carrying medical supplies to natural disasters and replacing ambulances that are slow to respond to emergencies in remote areas. This fits Africa’s needs.

    Italo Subbarao, Associate Dean of William Carey University College of Osteopathic Medicine, has built three drone prototypes that can support medical care needed for large-scale disasters. A study of the effects of the towering tornado that struck Hattiesburg, Mississippi in 2013 found that emergency medical responders were slowed down by fallen trees, power lines and debris as they tried to reach the injured. 

    Drones carrying medical supplies, cameras, microphones and interactive goggles can find survivors with an emergency doctor on the scene assessing victims, reading vital signs and administering emergency care. The drone concept doesn’t only fit large-scale emergencies. It can support doctors and other healthcare professionals dealing with serious local emergencies that need specific medical supplies.

    The drones’ potential’s confirmed by a Swedish research letter from a team at Karolinska Institutet, published in the Journal of the Journal of the American Medical Association (JAMA).  For 18 drone flights, average time to take off for delivery of a defibrillator was three seconds. They were an average of 17 minutes faster than in reaching the location of Out of Hospital Cardiac Arrests (OHCA). While this service carries a specific, pre-loaded drone, it points to the benefits of drones with bespoke payloads ordered by doctors attending a wider range of medical emergencies. It’s a new opportunity for Africa’s healthcare. 

  • Cyber-security training must be effective

    Now Africa has its own cyber-security advice, reported on eHNA, it’s important that health systems have effective training in place. The Internet Infrastructure Security Guidelines for Africa was unveiled by the Internet Society and the African Union Commission (AUC) at the African Internet Summit, in Nairobi. It has awareness as one of four core principles that have to be deployed. 

    A report from Enterprise Management Associates says cyber-security awareness programmes have a lot to learn. Already reported by eHNA, it says training that achieve better cyber-security awareness:

    • Involves interactive elements
    • Is continuous, with regular follow-ups
    • Simulates real-life attacks
    • Monitors users’ effectiveness.

    These are four criteria that Africa’s health system can adopt in applying this part of the AUC’s good practices.

  • Africa has five big SDG features

    Countries’ performance against Sustainable Development Goals (SDG) is set out in a report from WHO. World Health Statistics 2017: Monitoring health for the SDGs includes health data for SDG3 for Sub-Saharan Africa (SSA) and North Africa. Three features stand out, with most data for 2015.

    Of the 18 SDG3’s, a comparison of Africa’s performance with the percentage gap from the global average shows eleven are high scores that need improving, seven are low rates that need improving. Three stand out, with two others.

    Number 3 on the graph is life expectancy at birth. Number 6 is the number of people needing interventions for Neglected Tropical Diseases (NTD). Number 5 is the incidence of malaria. Two others are number 1, maternal mortality and 11’s the adolescent birth rate.

    Suicide mortality rate and alcohol consumption are 8 and 9. Africa has a good start on these.

    Taken as a whole, achieving the SDG3 goals is a considerable undertaking for most African countries. An average for North African countries shows they’re starting from a better baseline than SSA countries.

    How can eHealth help? With 18 targets across a range of often related health factors indicate that an effective eHealth approach’s to implement a solution with integrated architecture and Interoperability (IOp) where core data, such as patients’ IDs and health records are accessible by all end users. This will support both healthcare and public health endeavours to achieve SDG3’s goals.

  • Medical devices’ cyber-security testing’s not good enough

    As cyber-attacks expand, and since the alarm bells after WannaCry, reported on eHNA, cyber-security’s priority should’ve increased dramatically. It seems it’s starting from a low baseline for medical devices.

    A survey by Ponemon Institute for Synopsis says device suppliers think the chances of cyber-attacks on their products are 67%. US healthcare organisations as users think the probability’s 56%. These may be a bit low, but despite this, the survey shows only 5% of healthcare providers test their medical devices at least once a year. More alarmingly, 53% don’t test their cyber-security at all.

    A similar deficit prevails with device makers. Only 9% say they test their devices at least once a year. About 43% don’t test their device’s cyber-security. This highlights an important procurement criterion for Africa’s health systems.

    These are vulnerabilities that Africa’s health systems should address too. It’s especially critical when 80% of medical device makers and users say medical devices are very difficult to secure. Another vulnerability’s revealed by only 25% of respondents who say cyber-security protocols or architecture inside devices provide adequate protection for clinicians and patients.

    Medical Device Security: An Industry Under Attack and Unprepared to Defend says patients have already suffered from cyber-attacks and adverse events. About 31% of device makers and 40% of healthcare providers say they are aware of these. Of these, 38% of providers say inappropriate therapy or treatment was provided to patients. About 39% of device makers say cyber-attacks have taken control of their medical devices.             

    Ponemon’s report sets out a string of risks. They’re:

    • Device makers and users low confidence that patients and clinicians are protected
    • Using mobile devices affects healthcare organisations’ cyber-security’s risk postures. Clinicians depend upon their mobile devices to more efficiently serve patients
    • Budget increases to improve medical devices’ cyber-security often happen after a serious breach
    • Medical device security practices aren’t the most effective, relying on cyber-security requirements instead thorough practices such as testing
    • Most organisations don’t encrypt traffic between Internet of Thins (IoT) devices
    • Medical devices contain vulnerable code because of a lack of quality assurance and testing procedures and a rush to release
    • Testing rarely occurs, with only 9% of makers and 5% of users testing at least once a year
    • Accountability medical devices’ cyber-security is lacking
    • Makers and users aren’t aligned on current cyber-security risks, with healthcare providers more likely to be concerned about their devices’ cyber-security and risks, and suppliers’ lack of action to protect patients and users
    • Insufficient compliance with regulatory advice and guidance
    • Most makers and users don’t disclose their medical devices’ privacy and security risks. 

    Ponemon says makers and users say cyber-security’s hard to achieve. It suffers from accidental coding errors, lack of knowledge and training for secure coding practices and pressure on development teams to meet product deadlines. It seems that the clichéd paradigm shift’s needed.