Implementation of e-health interoperability in developing country contexts : the case of Zimbabwe

The provision of information technology-enabled healthcare services (e-health) has been adopted by numerous public and private facilities in both developing nations and advanced nations. However, one of the obstacles to the adoption of health information systems has been cited as their lack of interoperability resulting in their reduced effectiveness. In view of this, the study sought to explore the interoperability of health information systems employed in the country and then propose a framework to direct the process of implementing e-health interoperability. The study’s methodology was qualitative and a case study was undertaken. Semi-structured interviews were employed to gather data from e-health stakeholders in state-owned institutions and private enterprises. Document review was also conducted to substantiate findings from interviews. Data was analysed using thematic analysis and NVivo 12 software. The study’s findings revealed that several health information systems were implemented and their interoperability was low. Technological, terminology, organizational as well as regulatory and legal barriers were identified as hindrances to interoperability. The enablers for implementing e-health interoperability also revealed by this study include: development of re-usable software components, train the trainer approach to transfer of skills and regional conformance testing. The consequences of lack of interoperability among health information systems reported by this study include: burden on the worker, wastage of resources and high cost. The study also proposed a dual framework to guide the implementation of e-health interoperability. The study’s recommendations include the development of an e-health policy, an e-health strategy and the upgrade of ICT and telecommunication infrastructure to facilitate health information exchange.School of ComputingD. Phil. (Information Systems

Recommendations for a Global Framework to Support Health Information Exchange in Low- and Middle-Income Countries

Regenstrief Institut

Digital Re-imagination Colloquium 2018: Preparing South Africa for a Digital Future through e-Skills

The theme of the 2018 colloquium, "Digital Re-imagination: Preparing South Africa for a Digital Future through e-Skills" sought to establish an innovative research network through providing a platform for government, academia, industry, education and civil society to share research, data and trends that will contribute to refining the mandate to develop the necessary e-skills capacity of South Africa With the dawn of every new age, the nature of work and our relationships change. The impact of these changes to the digital economy affect entire systems of production, management, and governance. For example, government is currently designed as linear and mechanistic yet the digital economy is made up of adaptive systems. William Gibson has famously been quoted for the phrase: "The future is already here — it's just not very evenly distributed." Given the extant amount of data available today, it is now possible to predict (within some margins of error) how people will behave in certain situations. Data is increasingly becoming better structured and easy to access. The question is, are we ready for the future? Are we ready to harness the opportunities that the digital economy has brought? Can the digital economy make a better South Africa for all? Technology today is able to perform exponentially better than we can; how then can we create new industries and new forms of governance? It is critical to re-think how systems are being implemented. Creativity and innovation is big business in the digital economy. Creativity and innovation moves contributions to beyond the individual and the group - to societal, disciplinary, national and global level. The prevalent economic paradigm of a winner who takes it all means that the lower income earners are increasingly more dissatisfied. One of the symptoms of any illness is pain. Pain can be seen in our society in the form of unemployment, poverty and the dissatisfaction with the status quo. The challenges in our society cry out for change - a new way of thinking about employment, wealth creation and governance. What are the real opportunities that the digital economy presents to the people of South Africa? Real opportunities are those which are not only available substantively, but are also achievable by the people for who they are created. The opportunities presented by the digital economy can only become real if we e-skill people to take advantage of those opportunities. Countries in the East have been able to adapt technologies without giving up the cultural values they hold dear. While the challenges we face in South Africa may be seen as a problem, they also present an opportunity to make a difference with Digital Skills. It is no longer enough to have a skill; technology, talent and insight are becoming critical as well. The colloquium received 13 submissions. These submissions include four full papers, one concept note and eight abstracts. The submissions were all blind peer reviewed by at least two reviewers. None of the authors nor editors were involved in reviewing their own submissions.ICT4D Flagship, University of South Africa National Electronic Media Institute of South Africa (NEMISA)School of Computin

Facilitating health information exchange in low- and middle-income countries: conceptual considerations, stakeholders perspectives and deployment strategies illustrated through an in-depth case study of Pakistan

Background Health information exchange (HIE) may help healthcare professionals and policymakers make informed decisions to improve patient and population health outcomes. There is, however, limited uptake of HIE in many low- and middle-income countries (LMICs). While resource constraints are an obvious barrier to implementation of HIE, it is important to explore what other political, structural, technical, environmental, legal and cultural factors may be involved. In particular, it is necessary to understand associated barriers in relation to context-specific HIE processes and deployment strategies in LMICs with a view to discovering how these can be overcome. My home country Pakistan is currently struggling to implement HIE at scale and so I undertook a detailed investigation of these issues in the context of Pakistan to generate insights on how best to promote uptake of HIE in Pakistan and in LMICs more generally. Aims The concept of HIE is evolving both over time and by context. To gain a clearer understanding of this terrain, I began by identifying different definitions of HIE in the literature to understand how these had evolved and the underlying conceptual basis for these changes. Second, I sought to understand the barriers and facilitators to the implementation and adoption of HIE in LMICs. Building on this foundational work, I then sought to explore and understand in-depth stakeholders perspectives on the context of and deployment strategies for HIE in Pakistan with a view to also identifying potentially transferable lessons for LMICs. Methods I undertook a phased programme of work. Phase 1 was a scoping review of definitions, which involved systematically searching the published literature in five academic databases and grey literature using Google to identify published definitions of HIE and related terms. The searches covered the period from January 1900 to February 2014. The included definitions were thematically analysed. In Phase 2, to identify barriers and facilitators to HIE in LMICs, I conducted a systematic review and searched for published and on-going (conference papers and abstracts) qualitative, quantitative and mixed-method studies in 11 academic databases and looked for unpublished work through Google interface from January 1990 to July 2014. Eligible studies were critically appraised and then thematically analysed. Finally, in Phase 3 I conducted a case study of HIE in Pakistan. Data collection comprised of interviews of different healthcare stakeholders across Pakistan to explore attitudes to HIE, and barriers and facilitators to its deployment. I also collected evidence through observational field notes and by analysing key international, national and regional policy documents. I used a combination of deductive thematic analysis informed by the theory of Diffusion of Innovations in Health Service Organisations that highlighted attributes of the innovation, the behaviour of adopters, and the organisational and environmental influences necessary for the success of implementation; and a more inductive iterative thematic analysis approach that allowed new themes to evolve from the data. The findings from these three phases of work were then integrated to identify potentially transferable lessons for Pakistan and other LMICs. Results In Phase 1, a total of 268 unique definitions of HIE were identified and extracted: 103 from scientific databases and 165 from Google. Eleven attributes emerged from the analysis that characterised HIE into two over-riding concepts. One was the ‘process’ of electronic information transfer among various healthcare stakeholders and the other was the HIE ‘organisation’ responsible to oversee the legal and business issues of information transfer. The results of Phase 1 informed the eligibility criteria to conduct Phase 2, in which a total of 63 studies met the inclusion criteria. Low importance given to data informed decision making, corruption and insecurity, lack of training, lack of equipment and supplies, and lack of feedback were considered to be major challenges to implementing HIE in LMICs, but strong leadership and clear policy direction coupled with the financial support to acquire essential technology, provide training for staff, assessing the needs of individuals and data standardisation all promoted implementation. The results of Phases 1 and 2 informed the design and content of Phase 3, the Pakistan case study. The complete dataset comprised of 39 interviews from 43 participants (including two group interviews), field observations, and a range of local and national documents. Findings showed that HIE existed mainly in/among some hospitals in Pakistan, but in a patchy and fragmented form. The district health information system was responsible for electronically transferring statistical data of public health facilities from districts to national offices via provincial intermediaries. Many issues were attributed to the absence of effective HIE, from ‘delays in retrieving records’ to ‘the increase in antibiotic resistance’. Barriers and facilitators to HIE were similar to the findings in Phase 2, but new findings included problems perceived to be the result of devolution of health matters from the federal to provincial governments, the politicised behaviour of international organisations, healthcare providers’ resistance to recording consultations to avoid liability and poor documentation skills. Public pressure to adopt mobile technology frameworks was found to be a novel facilitator whereas sharing regional health information with international organisations was perceived by some participants as disadvantageous as there were concerns that it may have enhanced espionage activities in the region. Conclusions HIE needs to be considered in both organisational and process terms. Effective HIE is essential to the provision of high quality care and the efficient running of health systems. Structural, political and financial considerations are important barriers to promoting HIE in LMICs, however, strong leadership, vision and policy direction along with financial support can help to promote the implementation of HIE in LMICs. Similarly, the federal and provincial governments could play an important role in implementing HIE in Pakistan along with the support of international organisations by facilitating HIE processes at federal and provincial levels across Pakistan. This however seems unlikely for the foreseeable future. At a meso- and micro-level, HIE in Pakistan and other LMICs could be achieved through using leapfrog mobile technologies to facilitate care processes for local organisations and patients. Specifically, the study on Pakistan has highlighted that LMICs may achieve modest successes in HIE through use of patient held records and use of now ubiquitous mobile phone technology with some patient and organisational benefits, but scaling these benefits is dependent on the creation of national structures and strategies which are more difficult to achieve in the low advanced informatics skill and resource settings that characterise many LMICs

The Role of Innovation Intermediaries in Developing Healthcare Innovation Ecosystems: Value Co-Creation through Platforms

Thesis (PhD)--Stellenbosch University, 2021.ENGLISH ABSTRACT: Creating sustainable agile innovative environments is a persistent challenge, which has been exacerbated by the COVID-19 global pandemic. The disruption in services has highlighted the need to foster innovation, build resilient health systems, operationalise technology banks and build more domestic capacity whilst harnessing global cooperation. These are the mandates of the 3rd, 9th and 17th Sustainable Development Goals (SDGs). One organisation cannot maintain and develop these systemic dynamics alone, hence ecosystems of actors ranging in structure and size are formed. These are the foundational precepts of this dissertation as it explores how to manage innovation ecosystems. Though such concerns are across diverse industries, this study was in healthcare. The aim was to inform under-resourced countries on how to ensure sustainability on projects often funded by foreign funders, which is rampant in the Global South. This study contributed to the discourse of ecosystems research by developing an Ecosystem Evolution and Emergence Framework that assists in the management of the innovation ecosystem. Ecosystems research has mainly focussed on the structure of ecosystems and less attention has been devoted to the emergence of ecosystems. Thus,this study contributes to shedding some light on ecosystem emergence.The framework has two pillars for the innovation intermediary: outlining the key tasks to undertake at each ecosystem stage and the key aspects that are important to identify, monitor or cultivate in the ecosystem for the ecosystem actors. A constructivist perspective was used to better understand the relationship between innovation intermediation and innovation ecosystems. Conceptually, the framework development process was guided by Soft Systems Methodology with an emphasis on learning from the history of past projects addressing the same issues. These theoretical tools were deduced from established theories in innovation systems and complexity science embedded in a narrative explanation-Event Structure Analysis. This analysis was utilised through applying event colligation and displaying through Causal Loop Diagrams Empirically, a comparison of the emergence sequences from three healthcare innovation ecosystems was undertaken. These are the Maternal Alliance for Mobile Action (MAMA), Mom Connect and the District Health Information System (DHIS2). The activities and functions were mapped in the study across the innovation ecosystem development stages of birth, expansion and self-renewal using the framework. This resulted in the identification of 39 core ecosystem events deemed leverage points–each with a myriad of activities. The evaluated framework culminated in five distinct leverage categories of structural, technological, social, knowledge and political leverage. This is presented as an ecosystem management tool that enables: 1) building of innovation ecosystems; 2) facilitating improvement and sustainability of existing innovation ecosystems; and 3) providing the ecosystem manager with tools to address commonly experienced challenges. The tool’s main aim is to provide guidelines on how ecosystems emerge and are governed. The systematic approach followed in the study lends itself to future development and expansion with various other computerised tools.AFRIKAANSE OPSOMMING: Raadpleeg teks vir opsommingDoctorat

Public Health Decisions Using Point of Care Data from Open Source Systems in Africa

Objective: We demonstrate an architecture for driving regional public health decisions with automated and semi-automated data collected from open source point of care systems in resource constrained environments.Introduction: Ministries of Health in Low and Middle Income Countries (LMIC) are making or trying to make public health decisions for infectious disease conditions like HIV using data garnered from sentinel events and disease tracking in the community. The process of gathering and aggregating data for these case-based reports for is, in all too often a cumbersome or paper-based process. The Center for Disease Control (CDC) was interested in prototyping and piloting approaches that could improve the efficiency and reliability of case reports in resource-constrained environments. One of their primary goals was to demonstrate how electronic data gathered in the front lines of care could be leveraged to automate and improve the reliability of data within case reports driving public health decisions at regional and country levels. OpenMRS is an open source medical record system platform often used in resource constrained environments.1 Since OpenMRS is used as an electronic medical record system in several African countries and has been connected to regional or country-level health exchanges, the CDC was interested in building a working solution for electronic case based reporting using OpenMRS and a health information exchange.Methods: Working closely with the CDC, we developed a Case-Based Reporting (CBR) module for OpenMRS, using HIV as an initial use case. Trigger events were defined based on sentinel events and key clinical monitoring conditions and these were mapped or added to standard terminologies. We use Health Level 7 (HL7) messaging standards to deliver case reports from OpenMRS to the health information exchange.2 We used existing manual workflows and EPI officers to define the needs for a surveillance officer role and the requirements for the CBR module. The module was developed as open source using agile methodologies. OpenHIE (ohie.org) was selected to demonstrate the ability of OpenMRS module to submit an electronic case report to a health information exchange.Results: We have a working, open source case-based surveillance module for OpenMRS that comes with nine pre-defined HIV-specific triggers:● New Case● New Disease● New Treatment● Evidence of Lack of Monitoring● Evidence of Treatment Failure● Switched to Second Line Regimen● Treatment Stopped● Lost to Follow Up● Patient DiedWe have been able to demonstrate the automatic creation of HIV-based case reports based on data within an electronic medical record system, placement of these proposed case reports into a work queue for a surveillance officer, and successful electronic submission of these case reports into a health information exchange.Conclusions: This work demonstrates the ability to develop open source point of care software solutions for LMIC that can be used for sentinel awareness as well as longitudinal monitoring of individual patient care. The current scenarios, trigger identification standards, and messaging specifications are easily accessible and published on the OpenMRS Wiki.3Our incorporation of user centered design through EPI officer engagement helped ensure that our solution is responsive to the end user. The CDC is able to use this solution to demonstrate the feasibility of incorporating electronic case reporting in LMICs and to demonstrate the benefits and promote the adoption of electronic medical record systems and health information exchanges in resource constrained environments. In the next phase of this work, we will be working with the CDC to identify sites within Africa for deployment and refinement of the CBR module