Resources: Evaluating the benefits of health informatics

As in all innovations, evaluation of the benefits and risks is crucial. Below are some of the evaluations of health informatics, as they apply in developing countries in particular. There clearly is great potential - but a great deal of work to realise this potential.

Some potential benefits

We met the paper by Piette et al Impacts of e-health on the outcomes of care in low- and middle-income countries: where do we go from here? in the previous section “Although e-health tools supporting clinical practice have growing penetration globally, there is more evidence of benefits for tools that support clinical decisions and laboratory information systems than for those that support picture archiving and communication systems. Community information systems for disease surveillance have been implemented successfully in several low- and middle-income countries. Although information on outcomes is generally lacking, a large project in Brazil has documented notable impacts on health-system efficiency. Meta-analyses and rigorous trials have documented the benefits of text messaging for improving outcomes such as patients’ self-care. Automated telephone monitoring and self-care support calls have been shown to improve some outcomes of chronic disease management, such as glycaemia and blood pressure control, in low- and middle-income countries. Although large programmes for e-health implementation and research are being conducted in many low- and middle-income countries, more information on the impacts of e-health on outcomes and costs in these settings is still needed.”

mHealth - benefits and limitations

In Understanding the Role of mHealth and Other Media Interventions for Behavior Change to Enhance Child Survival and Development in Low- and Middle-Income Countries: An Evidence Review. Higgs et al conclude: "Overall, this review found that some mHealth interventions have sufficient evidence to make topic-specific recommendations for broader implementation, scaling, and next research steps (e.g., adherence to HIV/AIDS antiretroviral therapy, uptake and demand of maternal health service, and compliance with malaria treatment guidelines)."

A study Feasibility and Effectiveness of mHealth for Mobilizing Households for Indoor Residual Spraying to Prevent Malaria: A Case Study in Mali by Mangam et al concluded "Sending voice and/or text messages to mobilize households for spraying was more costly per structure and less effective at preparing structures than traditional door-to-door mobilization approaches supplemented with radio and town hall announcements...Future attempts at using mHealth approaches ...... should be done in a way that combines mHealth tools with more common human-based interventions, rather than as a stand-alone approach."

Electronic Health Records and disease surveillance - some benefits and dangers

Tierney et al, in  Assessing the impact of a primary care electronic medical record system in three Kenyan rural health centers. state “We successfully implemented a primary care EMR in three rural Kenyan health centers. Patient waiting time was dramatically lengthened while the nurses’ and the clerks’ patient care time decreased. Long-term use of EMRs in such settings will require changes in culture and workflow. “ “'Effective and efficient patient care management requires information. Improving information capture and flow should allow low-resource countries to deliver the most care and realize the best outcomes possible for the restricted funds available for health care. EMRs can enhance the timely capture and use of key medical data by providers and health system managers. Much additional research and development is needed before EMRs can be most useful, fully implemented into developing countries’ health care settings, and used to manage and improve patient care."

The impact of electronic records on patient safety: a qualitative study by Clarke et al found: "The first 12 months of introducing the maternity system was perceived to and in some cases had already caused actual risk to patient safety. Trusts throughout the NHS are facing increasing pressure to become paperless and should be aware of the  potential adverse impacts on patient safety that can occur when introducing electronic systems." 

Internet-based surveillance systems for monitoring emerging infectious diseases. "We review studies that have exploited internet use and search trends to monitor two such diseases: influenza and dengue. Internet-based surveillance systems have good congruence with traditional surveillance approaches. Additionally, internet-based approaches are logistically and economically appealing. However, they do not have the capacity to replace traditional surveillance systems; they should not be viewed as an alternative, but rather an extension. Future research should focus on using data generated through internet-based surveillance and response systems to bolster the capacity of traditional surveillance systems for emerging infectious diseases."

Implementing systems and the need for a trained workforce

In Health Informatics in Developing Countries: Going beyond Pilot Practices to Sustainable Implementations: A Review of the Current Challenges  Luna et al “describe the problems faced by developing countries arising from the lack of adequate infrastructure and the ways these can be bypassed; the fundamental need to develop nationwide e-Health agendas to achieve sustainable implementations; ways to overcome public uncertainty with respect to privacy and security; the difficulties shared with developed countries in achieving interoperability; the need for a trained workforce in health informatics and existing initiatives for its development; and strategies to achieve regional integration.”

In Digital Health Information System in Africa’s resource poor countries: current challenges and opportunities Sheikh states: "The continent’s ailing digital health system does not only require considerable attention and investment but consistent coordination and support within its current health services. Lack of investments in health information technology, and knowledge synthesis are the key factors lacking in many of the African countries’ strategic direction."

In Building A Health Informatics Workforce In Developing Countries. Hersh et al say: "One of the challenges to implementing health information and communication technology is the need for a skilled workforce that understands health care, information and communication technology, and the people and organizational challenges involved...... leaders need to be cognizant of the need for a well-trained workforce to lead their implementation. An ideal approach will include needs assessment as well as education and training opportunities for that workforce. Successful local examples can be expanded into larger networks whose scale can be leveraged to more rapidly and effectively disseminate them."

Information technology systems in public sector health facilities in developing countries: the case of South Africa  summarises: "This study examines the impact of hospital information systems implementation on service delivery, user adoption and organisational culture within two hospital settings in South Africa... The impact of automation in terms of cost and strategic value in public sector hospitals is shown to have yielded positive outcomes with regard to patient experience, hospital staff workflow enhancements, and overall morale in the workplace....it finds that sustainable success in these initiatives is as much a function of the technology as it is of the change management function that must accompany the system implementation."

More research is needed!

The paper E-Health Technologies Show Promise In Developing Countries by Blaya et al  summarises: “Our systematic review of evaluations of e-health implementations in developing countries found that systems that improve communication between institutions, assist in ordering and managing medications, and help monitor and detect patients who might abandon care show promise. Evaluations of personal digital assistants and mobile devices convincingly demonstrate that such devices can be very effective in improving data collection time and quality. Donors and funders should require and sponsor outside evaluations to ensure that future e-health investments are well-targeted. “

In Preparedness for e-Health in developing countries: the case of Ghana the authors summarised: “The literature review found the two highest priority objectives in in e-Health Africa: providing health education for health professionals (identified in 7 of the 16 projects reported on in the literature) and improvement of primary health care services 9 of the 16 projects). Six (6) or 39% each of the 16 projects reported a lack of skills and Human Resources Socioeconomic issues, and Technology infrastructure problems reported in 22% or the remaining four (4) projects. The paper concluded that the effects of these challenges could lead to Ghana like many other developing countries struggling to adopt e-Health, its inability to realize the potential benefits of e-Health and its ability to institutionalize and sustain e-Health.”

In What’s Past Is Prologue: A Scoping Review of Recent Public Health and Global Health Informatics Literature Dixon et al say: "While the body of knowledge around public health informatics (PHI) and global health informatics (GHI) continues to mature, additional studies of higher quality are needed to generate the robust evidence base needed to support continued investment in ICT by governmental health agencies." 

Managing change

A number of the evaluations above have indicated the importance of change management in the effective introduction of health informatics to an organisation. This presentation Managing Change in Healthcare IT Implementations suggests some methods of managing this change. We include this as the last part of the course, but are aware that the presentation does not have references, and the strategies the author proposes really do need to be evaluated themselves!