Correction: iCHECK-DH: Guidelines and Checklist for the Reporting on Digital Health Implementations

[This corrects the article DOI: 10.2196/46694.].

iCHECK-DH: Guidelines and Checklist for the Reporting on Digital Health Implementations

BACKGROUND

Implementation of digital health technologies has grown rapidly, but many remain limited to pilot studies due to challenges, such as a lack of evidence or barriers to implementation. Overcoming these challenges requires learning from previous implementations and systematically documenting implementation processes to better understand the real-world impact of a technology and identify effective strategies for future implementation.

OBJECTIVE

A group of global experts, facilitated by the Geneva Digital Health Hub, developed the Guidelines and Checklist for the Reporting on Digital Health Implementations (iCHECK-DH, pronounced "I checked") to improve the completeness of reporting on digital health implementations.

METHODS

A guideline development group was convened to define key considerations and criteria for reporting on digital health implementations. To ensure the practicality and effectiveness of the checklist, it was pilot-tested by applying it to several real-world digital health implementations, and adjustments were made based on the feedback received. The guiding principle for the development of iCHECK-DH was to identify the minimum set of information needed to comprehensively define a digital health implementation, to support the identification of key factors for success and failure, and to enable others to replicate it in different settings.

RESULTS

The result was a 20-item checklist with detailed explanations and examples in this paper. The authors anticipate that widespread adoption will standardize the quality of reporting and, indirectly, improve implementation standards and best practices.

CONCLUSIONS

Guidelines for reporting on digital health implementations are important to ensure the accuracy, completeness, and consistency of reported information. This allows for meaningful comparison and evaluation of results, transparency, and accountability and informs stakeholder decision-making. i-CHECK-DH facilitates standardization of the way information is collected and reported, improving systematic documentation and knowledge transfer that can lead to the development of more effective digital health interventions and better health outcomes.

Evaluation of the Efficiency of Telemedicine in the Management of Cardiovascular Diseases in Primary Healthcare in Sub-Saharan Africa: A Medico-Economic Study in Cameroon

OBJECTIVE

To assess the efficiency of tele-expertise (tele-ECG) for patients and for health facilities in managing patients with cardiovascular diseases (CVDs) in primary health care in Cameroon.

METHOD

This study was a medico-economic study combining two approaches: cost minimization and cost-effectiveness analysis. It was conducted alongside the previous published controlled multicenter study carried out in Cameroon's two health facilities where tele-ECG has been implemented (intervention centres) and two other where telemedicine has been not implemented (control centres).

RESULTS

The average total cost for patients was 9 286 F CFA (US$: 16) in the intervention centres compared to 28 357 F CFA (US$: 49) in the control centres (p <0.01). The calculated ICER favouring tele-ECG was 25 459.6 F CFA (US$: 44).

DISCUSSION

Telemedicine is efficient for managing patients with CVDs in primary health care in Cameroon. It enables health facilities in remote areas to offer new healthcare services at a lower cost and improve patients' financial access to healthcare.

État des lieux du système d’information sanitaire du Gabon

OBJECTIVE

The need for an efficient and reliable health information system motivated Gabon, with the support of the World Bank, to finance a project to reinforce its health information system. An&#160;audit of this system was required to report on the reality of the existing system and tools.

METHODS

Over the course of two periods, May to September&#160;2016 and April to May&#160;2018, information was collected using both qualitative and quantitative approaches. In this framework, were carried out successively: participative workshops including health actors in Gabon, a survey of health care workers, an analysis of reference documents relating to national health policies, and an analysis of the strengths, weaknesses, opportunities, and threats to the system.

RESULTS

In total, 171&#160;health care professionals participated in the different workshops, and 770&#160;others were questioned among 150&#160;health care establishments from 10&#160;health care regions of the country. At the end of this research work, organizational and technical problems were noted at the level of the health information system of Gabon, notably the absence of a judicial framework defining the roles and responsibilities of the different actors of the system, weak data management, a stovepipe information system, several non-interoperable IT applications, and weak completeness rate, at 30%. Among the 770&#160;health care professionals surveyed, 539 (70%) were favorable to a new information system. As for the main assets, we noted the existence of computing equipment and acceptable internet coverage, 31.5% of the health care establishments are connected via cable.

CONCLUSION

This research sheds light on the existing health information system and should enable the implementation of a new system.

Implementation of a national electronic health information system in Gabon: a survey of healthcare providers' perceptions

BACKGROUND

The Health Information System (HIS) is a set of computerized tools for the collection, storage, management, and transmission of health data. The role of such tools in supporting the modernization of health systems, improving access to quality healthcare, and reducing costs in developing countries is unquestionable, but their implementation faces several challenges. In Gabon, a unique national electronic HIS has been launched. It will connect healthcare institutions and providers at all levels in the whole country.

OBJECTIVE

This study aims to explore and identify the factors influencing healthcare providers' perceptions of the national electronic HIS in Gabon.

METHODS

A 44-item questionnaire based on the Information System Success Model (ISSM) was administered between February and April 2018 among 2600 healthcare providers across the country. The questions assessed the different aspects of the HIS that could influence its perceived impact on a 5-level Likert scale (from fully agree to totally disagree). The reliability and construct validity of the questionnaire were checked using Cronbach alpha and congeneric reliability coefficients. A logistic regression was used to identify the factors influencing healthcare providers' perceptions of the system.

RESULTS

A total of 2327 questionnaires were completed (i.e. 89.5% response rate). The logistic regression identified five elements that significantly influenced perceived system impact: System Quality (Odds Ratio-OR = 1.70), Information Quality (OR = 1.69), Actual Use (OR = 1.41), Support Quality (OR = 1.37), and Useful Functions (OR = 1.14). The model explained 30% of the variance in providers' perception that the national HIS leads to positive impacts.

DISCUSSION

The results show that healthcare providers' perceptions regarding the positive impact of the national HIS in Gabon are influenced by their previous use of an HIS, the scope of their usage, and the quality of the system, information, and support provided to users. These results could inform the development of strategies to ensure adequate change of management and user experience for the implementation of the national HIS in Gabon, and eventually in other low resource environments.

A Teledermatology Pilot Programme for the Management of Skin Diseases in Primary Health Care Centres: Experiences from a Resource-Limited Country (Mali, West Africa)

In sub-Saharan Africa, in particular in rural areas, patients have limited access to doctors with specialist skills in skin diseases. To address this issue, a teledermatology pilot programme focused on primary health centres was set up in Mali. This study was aimed at investigating the feasibility of this programme and its impact on the management of skin diseases. The programme was based on the store-and-forward model. Health care providers from 10 primary centres were trained to manage common skin diseases, to capture images of skin lesions, and to use an e-platform to post all cases beyond their expertise for dermatologists in order to obtain diagnosis and treatment recommendations. After training, the cases of 180 patients were posted by trained health workers on the platform. Ninety-six per cent of these patients were properly managed via the responses given by dermatologists. The mean time to receive the expert’s response was 32 h (range: 13 min to 20 days). Analysis of all diseases diagnosed via the platform revealed a wide range of skin disorders. Our initiative hugely improved the management of all skin diseases in the targeted health centres. In developing countries, Internet accessibility and connection quality represent the main challenges when conducting teledermatology programmes.

The influence of a telehealth project on healthcare professional recruitment and retention in remote areas in Mali: A longitudinal study

Objectives:

The telehealth project EQUI-ResHuS (in French, Les TIC pour un accès Équitable aux Ressources Humaines en Santé) aimed to contribute to more equitable access to care and support practice in remote regions in Mali. This study explored the evolution of perceptions concerning telehealth among healthcare professionals in the four district health centres that participated in the EQUI-ResHus project and identified variables influencing their perceptions of telehealth impact on recruitment and retention of health professionals.

Methods:

One year after a first survey (T1), a second data collection (T2) was carried out among healthcare professionals using a 91-item questionnaire. Questions assessing telehealth use and perceptions and perceived impact on recruitment and retention of healthcare professionals were rated on a 5-point Likert scale. A total of 10 independent variables were considered for the analyses. A Wilcoxon signed-rank test was performed to detect differences between T1 and T2, and a bivariate linear regression model for repeated measures was carried out to assess the impact of independent variables on dependent variables.

Results:

There were no noticeable changes in perceptions related to telehealth influence on recruitment and retention. Only access to information and communication technology significantly differed between T1 and T2 according the Wilcoxon rank test (p = 0.001). Perceived influence of telehealth on recruitment and retention was mostly explained by attitude towards telehealth, perceived effect on recruitment and retention and barriers to recruitment and retention.

Conclusion:

Based on our results, telehealth was perceived as having a positive influence but mostly indirect influence on healthcare professional recruitment and retention. Also, there were no major changes after 1 year of telehealth use.

Reverse innovation experiences from the RAFT e-learning and telemedicine network

Available infrastructure, resources, and provided services in low-and middle-income countries differ significantly from high-income countries. In healthcare for example, the uneven distribution of health professionals and lack of human resources are real barriers to equitable access to quality health care and services in most developing countries and particularly in Sub-Saharan Africa. As available resources are lower and infrastructure is les developed many services and tools that have been developed for a high-income context cannot be used or are not sustainably affordable in a low-income environment, which led to the development of tools and services that are affordable and appropriate for this context. This ranges from concepts of blended learning, over tools for distance education and diagnostic to hardware like affordable and robust ultrasound machines and services like mobile payment. Many of these solutions and tools also have a great potential to be utilized in a different context and some of them have been deployed in high-income countries.

Social Network and Health Researchers and Professionals Mobility in Africa: Lessons Learned from AFRICA BUILD Project

OBJECTIVE

Promote mobility between South-South and South-North for improving level of researchers, staff and students through a platform.

METHODS

The methodology is based a filling of a questionnaire about offer or demand. Material is composed a computer connected Internet.

RESULT

we registered about 203 demands and 31 offers from partners.43 mobilities were executed completely.

CONCLUSION

The results indicate a real need of mobility for researchers and health professionals in Africa. The important number of mobility demands made by external researchers and professionals (from outside the AFRICA BUILD Consortium) may be constrained by the difficulty to find adequate funding.

The RAFT Telemedicine Network: Lessons Learnt and Perspectives from a Decade of Educational and Clinical Services in Low- and Middle-Incomes Countries

BACKGROUND

The objectives of this paper are to (i) provide an overview of the educational and clinical experiences of the Réseau en Afrique Francophone pour la Télémédecine (RAFT) network, (ii) analyze key challenges and lessons learnt throughout a decade of activity, and (iii) draw a vision and perspectives of its sustainability.

METHODS

The study was carried out following three main stages: (i) a literature review, (ii) the analysis of key documents, and (iii) discussions with key collaborators of the RAFT.

RESULTS

Réseau en Afrique Francophone pour la Télémédecine has been offering an important quantity of educational, clinical, and public health activities during the last decade. The educational activities include the weekly delivery of video-lectures for continuing and post-graduate medical education, the use of virtual patients for training in clinical decision making, research training activities using ICTs and other e-learning activities. The clinical and public health activities include tele-expertise to support health professionals in the management of difficult clinical cases, the implementation of clinical information systems in African hospitals, the deployment of mHealth projects, etc. Since 2010, the RAFT has been extended to the Altiplano in Bolivia and Nepal (in progress). Lessons Learnt and Perspectives: Important lessons have been learnt from the accumulated experiences throughout these years. These lessons concern: social and organization, human resources, technologies and data security, policy and legislation, and economy and financing. Also, given the increase of the activities and the integration of eHealth and telemedicine in the health system of most of the countries, the RAFT network faces many other challenges and perspectives such as learning throughout life, recognition, and valorization of teaching or learning activities, the impact evaluation of interventions, and the scaling up and transferability out of Africa of RAFT activities. Based on the RAFT experience, effective integration and optimum use of eHealth and telemedicine in low- and middle-income countries (LMICs) health systems should take into account the context (resources, infrastructure, and funding), the needs of key stakeholders, and the results derived from theoretical and practical experience. The relevant items highlighted to illustrate the sustainability of the RAFT network and the analyses performed in this study, should serve as discussion basis for the development of eHealth and telemedicine in LMICs.

Medical and economic benefits of telehealth in low- and middle-income countries: results of a study in four district hospitals in Mali

Background

The aim of this study was to evaluate the impact of telehealth on 1) the diagnosis, and management in obstetrics and cardiology, 2) health care costs from patients’ perspectives, 3) attendance at health centres located in remote areas of Mali.

Methods

The impact of telehealth on health care utilization, quality, and costs was assessed using a five-point Likert-scale based questionnaire consisting of three dimensions. It was completed by health care professionals in four district hospitals. The role of telehealth on attendance at health centres was also assessed based on data collected from the consultations logs before and during the project, between project sites and control sites. Referrals specific to the activities of the research study were also evaluated using a questionnaire to measure the real share of telehealth tools in increasing attendance at project sites. Finally, the cost savings achieved was estimated using the transport and lodging costs incurred if patients were to travel to the capital city for the same tests or care.

Results

The telehealth activities contributed to improving medical diagnoses in cardiology and obstetrics (92.6%) and the patients’ management system on site (96.2%). The attendance records at health centres increased from 8 to 35% at all project sites during the study period. Patients from project sites saved an average of 12380 XOF (CFA Francs) or 25 USD (American dollar) and a maximum of 35000 XOF or 70 USD compared to patients from neighbouring sites, who must go to the capital city to receive the same care.

Conclusion

We conclude that in Mali, enhanced training in ultrasound / electrocardiography and the introduction of telehealth have improved the health system in remote areas and resulted in high levels of appropriate diagnosis and patient management in the areas of obstetrics and cardiology. Telehealth can also significantly reduce the cost to the patient.

Enhancing research capacity of African institutions through social networking

Traditionally, participation of African researchers in top Biomedical Informatics (BMI) scientific journals and conferences has been scarce. Looking beyond these numbers, an educational goal should be to improve overall research and, therefore, to increase the number of scientists/authors able to produce and publish high quality research. In such scenario, we are carrying out various efforts to expand the capacities of various institutions located at four African countries - Egypt, Ghana, Cameroon and Mali - in the framework of a European Commission-funded project, AFRICA BUILD. This project is currently carrying out activities such as e-learning, collaborative development of informatics tools, mobility of researchers, various pilot projects, and others. Our main objective is to create a self-sustained South-South network of BMI developers.

Can ICTs contribute to the efficiency and provide equitable access to the health care system in Sub-Saharan Africa? The Mali experience

OBJECTIVE

The aim of this study is to demonstrate from actual projects that ICT can contribute to the balance of health systems in developing countries and to equitable access to human resources and quality health care service. Our study is focused on two essential elements which are: i) Capacity building and support of health professionals, especially those in isolated areas using telemedicine tools; ii) Strengthening of hospital information systems by taking advantage of full potential offered by open-source software.

METHODS

Our research was performed on the activities carried out in Mali and in part through the RAFT (Réseau en Afrique Francophone pour la Télémédecine) Network. We focused mainly on the activities of e-learning, telemedicine, and hospital information systems. These include the use of platforms that work with low Internet connection bandwidth. With regard to information systems, our strategy is mainly focused on the improvement and implementation of open-source tools.

RESULTS

Several telemedicine application projects were reviewed including continuing online medical education and the support of isolated health professionals through the usage of innovative tools. This review covers the RAFT project for continuing medical education in French-speaking Africa, the tele-radiology project in Mali, the "EQUI-ResHuS" project for equal access to health over ICT in Mali, The "Pact-e.Santé" project for community health workers in Mali. We also detailed a large-scale experience of an open-source hospital information system implemented in Mali: "Cinz@n".

CONCLUSION

We report on successful experiences in the field of telemedicine and on the evaluation by the end-users of the Cinz@n project, a pilot hospital information system in Mali. These reflect the potential of healthcare-ICT for Sub-Saharan African countries.

Relevance and usability of a computerized patient simulator for continuous medical education of isolated care professionals in sub-saharan Africa

OBJECTIVE

to explore the relevance and usability of using a computerized patient simulator as a tool for continuous medical education and decision support for health professionals in district hospitals in Sub-Saharan Africa.

METHODS

based on the diagnosis pathway and decision analysis in uncertainty context, interactive clinical vignettes are developed using VIPS, a computerized patient simulator, taking into account clinical problem situations whose relevance was identified. Vignettes were adapted to take into account local epidemiology, availability of diagnostic and therapeutic resources, and local socio-cultural constraints. The evaluation on VIPS software was made by care professionals and students.

RESULTS

a computerized patient simulator can be used to provide initial and continuing medical education in Sub-Saharan Africa. But many challenges exist.

CONCLUSION

further research is needed to measure potential improvements in knowledge, skills, decision-making abilities as well as patient outcome.

Deploying portable ultrasonography with remote assistance for isolated physicians in Africa: lessons from a pilot study in Mali

OBJECTIVE

Demonstrate the feasibility of deploying portable ultrasonography with remote assistance to improve the diagnostic capabilities of isolated physicians in Africa.

METHODS

The approach is based on the training of general practitioners for the use of ultrasonography, and the remote support by radiologists using dedicated tools for image transfer over low-bandwidth internet connections.

RESULTS

Our early results in a pilot project in Mali show that this approach is feasible, and that isolated physicians can productively use ultrasonography to improve diagnosis and management decisions such as the need for a medical evacuation towards a reference hospital.

CONCLUSION

These encouraging early results must be confirmed by larger-scale studies, in order to better understand the organizational requirements and demonstrate outcomes and return on investments for such telemedicine services. This scale-up project will start in 2010 in collaboration with the International Development Research Center of Canada.

Medical decision support systems in Africa

OBJECTIVE

To present an overview of the current state of computer-based medical decision support systems in Africa in the areas of public health, patient care, and consumer support.

METHODS

Scientific and gray literature reviews complemented by expert interviews.

RESULTS

Various domains of decision support are developed and deployed in Sub-Saharan Africa: public health information systems, clinical decision-support systems, and patient-centred decision-support systems.

CONCLUSIONS

Until recently, most of these systems have been deployed by international organizations without a real ownership policy entrusted to the African stakeholders. Many of these endeavours have remained or ceased at the experimentation stage. The multiplicity of organizations has led to the deployment of fragmented systems causing serious interoperability problems. In addition to basic infrastructures, these studies also highlight the importance of good organization, training and support, as key to the success and sustainability of these decision support systems.

The RAFT network: 5 years of distance continuing medical education and tele-consultations over the Internet in French-speaking Africa

Continuing education of healthcare professionals is a key element for the quality and efficiency of a health system. In developing countries, this activity is usually limited to capitals, and delocalized professionals do not have access to such opportunities, or to didactic material adapted to their needs. This limits the interest of such professionals to remain active in the periphery, where they are most needed to implement effective strategies for prevention and first-line healthcare. Telemedicine tools enable the communication and sharing of medical information in electronic form, and thus facilitate access to remote expertise. A physician located far from a reference center can consult its colleagues remotely in order to resolve a difficult case, follow a continuous education course over the Internet, or access medical information from digital libraries or knowledge bases. These same tools can also be used to facilitate exchanges between centers of medical expertise: health institutions of a same country as well as across borders. Since 2000, the Geneva University Hospitals have been involved in coordinating the development of a network for eHealth in Africa (the RAFT, Réseau en Afrique Francophone pour la Télémédecine), first in Mali, and now extending to 10 French-speaking African countries. The core activity of the RAFT is the webcasting of interactive courses. These sessions put the emphasis on knowledge sharing across care professionals, usually in the form of presentations and dialogs between experts in different countries. The technology used for the webcasting works with a slow (25 kbits/s) internet connection. Other activities of the RAFT network include visioconferences, teleconsultations based on the iPath system, collaborative knowledge bases development, support for medical laboratories quality control, and the evaluation of the use of telemedicine in rural areas (via satellite connections) in the context of multisectorial development. Finally, a strong emphasis is put on the development of capacities for the creation, maintenance, and publication of quality medical didactic contents. Specific courses are organized for the national coordinators of the network to develop these competencies, with the help of the Health-On-the-Net Foundation. The richness of the plurality of knowledge and know-how must be steered towards emulation and sharing, respectful of each partner's identity and culture. Collaborations with UNESCO and WHO have been initiated to address these challenges.

Assessment of Internet-based tele-medicine in Africa (the RAFT project)

The objectives of this paper on the Réseau Afrique Francophone de Télémédecine (RAFT) project are the evaluation of feasibility, potential, problems and risks of an Internet-based tele-medicine network in developing countries of Africa. The RAFT project was started in Western African countries 5 years ago and has now extended to other regions of Africa as well (i.e. Madagascar, Rwanda). A project for the development of a national tele-medicine network in Mali was initiated in 2001, extended to Mauritania in 2002 and to Morocco in 2003. By 2006, a total of nine countries are connected. The entire technical infrastructure is based on Internet technologies for medical distance learning and tele-consultations. The results are a tele-medicine network that has been in productive use for over 5 years and has enabled various collaboration channels, including North-to-South (from Europe to Africa), South-to-South (within Africa), and South-to-North (from Africa to Europe) distance learning and tele-consultations, plus many personal exchanges between the participating hospitals and Universities. It has also unveiled a set of potential problems: (a) the limited importance of North-to-South collaborations when there are major differences in the available resources or the socio-cultural contexts between the collaborating parties; (b) the risk of an induced digital divide if the periphery of the health system in developing countries is not involved in the development of the network; and (c) the need for the development of local medical content management skills. Particularly point (c) is improved through the collaboration between the various countries as professionals from the medical and the computer science field are sharing courses and resources. Personal exchanges between partners in the project are frequent, and several persons received an education at one of the partner Universities. As conclusion, we can say that the identified risks have to be taken into account when designing large-scale tele-medicine projects in developing countries. These problems can be mitigated by fostering South-South collaboration channels, by the use of satellite-based Internet connectivity in remote areas, the appreciation of local knowledge and its publication on-line. The availability of such an infrastructure also facilitates the development of other projects, courses, and local content creation.