Introduction
- What “digital health” is and its potential applications
- The potential risks and benefits of digital health interventions
- Implementing a digital health intervention (DHIS 2) in a LMIC
- What we learned
- A forward look
Digital health
Is a very broad term! (link)
Meaning: any use of information and communications technologies (ICT) for improving health and/or well-being
- By individuals e.g. mobile apps (COVID-19), wearables
- By healthcare providers e.g. remote consultation, diagnosis, treatment, monitoring
- For health information management e.g. EHR, imaging, diagnostics, omics, big data
- Use of analytics (e.g. AI) or algorithms with health data
- Research & development
- Personalised medicine, robotics, IoT, virtual reality, e-learning, e-pharmacy and any other emerging digital trend you care to mention…
Similar/overlapping terms: eHealth, mHealth, telehealth, telemedicine, health IT, health informatics
Digital health
Potential benefits include:
- Improved self-management of non-communicable diseases
- Improved access to healthcare/universal health coverage
- Improved healthcare and health outcomes
- Public health
- Greater opportunities for health promotion and prevention
- Strengthened surveillance and outbreak response
Lots of digital health “buzz”, initiatives, reports, strategies, pilots
Evidence base growing but…
“Yet, despite their potential, the myriad of digital health solutions often lack a clear strategy and purpose. Consequently, they struggle to progress beyond the pilot phase, to become financially viable and integrate into national health policies and systems.” (link)
Digital health
Digital Health resolution passed by WHA in 2018
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”… urging Member States to prioritize the development and greater use of digital technologies in health as a means of promoting Universal Health Coverage and advancing the Sustainable Development Goals”
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“…to build capacity for rapid response to disease incidents and public health emergencies, leveraging the potential of digital information and communication technology to enable multidirectional communications, feedback loops and data-driven “adaptive management""
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“to develop, as appropriate, legislation and/or data protection policies around issues such as data access, sharing, consent, security, privacy, interoperability and inclusivity consistent with international human rights obligations”
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mentioned WHO Strategy here
Evidence base
Success factors for digital health interventions
- Leadership, governance, stakeholder/intersectoral collaboration
- Enabling public health/data protection legislation
- Sustainability (funding, technologies)
- Interoperability, standards, common identifiers
- Scalability
- Integration with existing systems/pilots, flows, linkages
- Information security and cybersecurity
- Connectivity (Internet, mobile/SMS, computers)
- Functionality of chosen platform
- User experience
- Workforce development (e.g. IT skills)
Principles for digital development
- Design with the user
- Understand the existing ecosystem
- Design for scale
- Build for sustainability
- Be data driven
- Use open standards, open data, open source and open innovation
- Reuse and improve
- Address privacy and security
- Be collaborative
Requirements
- Sustainable - ideally open source (vs bespoke/commercial)
- Strong on data quality and information security
- Easy to use
- Key functionality including analytics and interoperability with other software
- Future-proof upgrade cycle
District Health Information System 2 (DHIS 2) (link)
Strengths
- Open source: no licensing costs or restrictions on customisation
- Well documented; extensive training materials; easy to use
- Interoperability: use of standards (e.g. ADX data format), Application Programming Interface (API), Python/R interoperability
- Strong focus on cybersecurity and fine-grained permissions for users
- Highly scalable
- Flexible data collection, including mobile devices, SMS
- Extensive analytical functionality including GIS
- Enterprise-level database/data warehouse
- Developers can add new apps
Weaknesses
- Technical skills required
- Set up time (e.g. metadata)
- Not suitable for all purposes e.g. LIMS, ? EBS
Open source software
Distributed, shared, open software development
No purchase/licensing costs
- Note that a single user licence for commercial software may far exceed the average national wage in LMIC
- OSS not cost-free: still need to pay for hosting, IT staff, training
60% of the Web (and most email) runs on the open source Linux operating system
Other examples of OSS
| KoBoToolbox | OpenELIS |
| OpenMRS | CommCare |
| Community Health Toolkit | mHero |
| OpenSRP | DIVOC |
| GOFR | SORMAS |
| RapidPro | ODK |
| COVID Credentials Initiative | And many more … |
What have we learned?
Technology decision-making
- Assessment of needs, capabilities, connectivity etc is hard; scope creeps
- Sustainable software solutions: open source (under-used) vs. bespoke (over-used) vs. commercial (unaffordable)
- Interoperability, use of standards: important for future capability, but linkage is difficult
- Sustainable hosting: the cloud is cheap (but unclear data governance may hinder); hosting it yourselves requires kit, dependable power supply, people (+/-) IT training …
- Metadata required for system configuration: master facility list (+ codes), denominator data, citizen ID system, GIS data
- Skills required for implementation team, e.g. Linux, networking, cybersecurity, Java, nginx, HTTPS/TLS, SSH, PostgreSQL, ufw, fail2ban, tripwire, SSH, virtualisation, Lynis, CloudFlare, Web development, system administration/shell scripting, (DHIS 2) - employ IT people!
Information governance/security and cybersecurity
- Lack of clear information governance may enable or hinder
- Much poor information security practice
- Default to basic principles (confidentiality, integrity, authenticity) or own organisational practices
- Key area to develop and strengthen, e.g. policy
Be lucky!
- Good colleagues and engaged IT
- Leverage metadata of existing DHIS 2 implementations
- Data centre
- Bet on DHIS 2 came good