Patient-Specific Mobile Phone-Generated Reminders and Quality of Hypertension Care in Western Kenya

To evaluate the impact of clinician-targeted mHealth-generated care suggestions on compliance with hypertension care guidelines in a resource-limited setting. This study was conducted in 10 rural health clinics in Western Kenya that offered hypertension care through nurses and clinical officers. Sites were grouped into intervention and control groups. Intervention group clinicians had patient-specific care suggestions triggered and displayed on a mobile application, mUzima, for their action. Care suggestions were also triggered in the mHealth application for control arm clinicians but were not displayed. Differences in compliance with hypertension care guidelines were evaluated. The study involved 378 patients with hypertension who had care suggestions generated during visits (217 in intervention group and 161 in control group). There was a higher proportion of adherence to hypertension care guidelines in the intervention group compared to the control group (91.1% vs. 85.7%, p=0.014). The random effects model showed significant variability in compliance rates among study clinicians (variance of 0.44, 95% CI: 0.12 -1.62). When displayed care suggestions were rejected by intervention providers, the most common reason given was 'Previously ordered' (58.8%). Clinicians felt that care suggestions improved awareness of hypertension care guidelines. The successful scaled implementation of mUzima with patient specific care suggestions led to higher adherence to hypertension care guidelines and improved quality of hypertension care. Tailormade m-Health applications in resource constrained settings for hypertension care and other chronic non-communicable diseases has the potential to lead to better adherence to care guidelines and quality of care.

PEERNaija-a mobile health platform incentivizing medication adherence among youth living with HIV in Nigeria: study protocol for a randomized controlled trial

BACKGROUND

Poor medication adherence is a major barrier to HIV control among youth living with HIV (Y-PLWH). The PEERNaija application (app) is an adapted smartphone app grounded in social cognitive and contigency management theories and designed to harness peer-based social incentives and conditional financial incentives to promote medication adherence. The app delivers a multifaceted medication adherence intervention including (1) peer-based social incentives, (2) financial incentives, (3) virtual peer social support, and (4) early clinic-based outreach for non-adherent Y-PLWH. A pilot trial of the app will be conducted in Nigeria, Africa's most populous country with the 4th largest HIV epidemic, and home to 10% of the world's four million Y-PLWH.

METHODS

In this randomized controlled trial, we will compare implementation outcomes (feasibility, acceptability, appropriateness measured via validated scales, enrollment and application installation rates, feedback surveys and focus group discussions with participants, and back-end application data), and preliminary efficacy (in improving medication adherence and viral suppression) of the PEERNaija app at 6 months. Participants in Arm 1 (PEERNaija) will receive daily medication reminders, peer-based social incentives, and virtual peer social support. Participants in Arm 2 (PEERNaija +) will additionally receive a conditional financial incentive based on their adherence performance. Eligibility for Y-PLWH includes (1) being aged 14-29 years, (2) being on ART, (3) owning a smartphone, (4) being willing to download an app, and (5) being able to read simple text in English.

DISCUSSION

This study will serve as the basis for a larger intervention trial evaluating the PEERNaija app (and the integration of mHealth, incentive, and peer-support-based strategies) to improve HIV outcomes in a critically important region of the world for Y-PLWH.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT04930198. First submitted date: May 25, 2021. Study start: August 1, 2021, https://clinicaltrials.gov/ .

PROTOCOL VERSION

January 21, 2022.

Differences in Health Professionals' Engagement With Electronic Health Records Based on Inpatient Race and Ethnicity

Importance

US health professionals devote a large amount of effort to engaging with patients' electronic health records (EHRs) to deliver care. It is unknown whether patients with different racial and ethnic backgrounds receive equal EHR engagement.

Objective

To investigate whether there are differences in the level of health professionals' EHR engagement for hospitalized patients according to race or ethnicity during inpatient care.

Design, Setting, and Participants

This cross-sectional study analyzed EHR access log data from 2 major medical institutions, Vanderbilt University Medical Center (VUMC) and Northwestern Medicine (NW Medicine), over a 3-year period from January 1, 2018, to December 31, 2020. The study included all adult patients (aged ≥18 years) who were discharged alive after hospitalization for at least 24 hours. The data were analyzed between August 15, 2022, and March 15, 2023.

Exposures

The actions of health professionals in each patient's EHR were based on EHR access log data. Covariates included patients' demographic information, socioeconomic characteristics, and comorbidities.

Main Outcomes and Measures

The primary outcome was the quantity of EHR engagement, as defined by the average number of EHR actions performed by health professionals within a patient's EHR per hour during the patient's hospital stay. Proportional odds logistic regression was applied based on outcome quartiles.

Results

A total of 243 416 adult patients were included from VUMC (mean [SD] age, 51.7 [19.2] years; 54.9% female and 45.1% male; 14.8% Black, 4.9% Hispanic, 77.7% White, and 2.6% other races and ethnicities) and NW Medicine (mean [SD] age, 52.8 [20.6] years; 65.2% female and 34.8% male; 11.7% Black, 12.1% Hispanic, 69.2% White, and 7.0% other races and ethnicities). When combining Black, Hispanic, or other race and ethnicity patients into 1 group, these patients were significantly less likely to receive a higher amount of EHR engagement compared with White patients (adjusted odds ratios, 0.86 [95% CI, 0.83-0.88; P < .001] for VUMC and 0.90 [95% CI, 0.88-0.92; P < .001] for NW Medicine). However, a reduction in this difference was observed from 2018 to 2020.

Conclusions and Relevance

In this cross-sectional study of inpatient EHR engagement, the findings highlight differences in how health professionals distribute their efforts to patients' EHRs, as well as a method to measure these differences. Further investigations are needed to determine whether and how EHR engagement differences are correlated with health care outcomes.

Recommendations of the International Medical Informatics Association (IMIA) on Education in Biomedical and Health Informatics: Second Revision

BACKGROUND

The purpose of educational recommendations is to assist in establishing courses and programs in a discipline, to further develop existing educational activities in the various nations, and to support international initiatives for collaboration and sharing of courseware. The International Medical Informatics Association (IMIA) has published two versions of its international recommendations in biomedical and health informatics (BMHI) education, initially in 2000 and revised in 2010. Given the recent changes to the science, technology, the needs of the healthcare systems, and the workforce of BMHI, a revision of the recommendations is necessary.

OBJECTIVE

The aim of these updated recommendations is to support educators in developing BMHI curricula at different education levels, to identify essential skills and competencies for certification of healthcare professionals and those working in the field of BMHI, to provide a tool for evaluators of academic BMHI programs to compare and accredit the quality of delivered programs, and to motivate universities, organizations, and health authorities to recognize the need for establishing and further developing BMHI educational programs.

METHOD

An IMIA taskforce, established in 2017, updated the recommendations. The taskforce included representatives from all IMIA regions, with several having been involved in the development of the previous version. Workshops were held at different IMIA conferences, and an international Delphi study was performed to collect expert input on new and revised competencies.

RESULTS

Recommendations are provided for courses/course tracks in BMHI as part of educational programs in biomedical and health sciences, health information management, and informatics/computer science, as well as for dedicated programs in BMHI (leading to bachelor's, master's, or doctoral degree). The educational needs are described for the roles of BMHI user, BMHI generalist, and BMHI specialist across six domain areas - BMHI core principles; health sciences and services; computer, data and information sciences; social and behavioral sciences; management science; and BMHI specialization. Furthermore, recommendations are provided for dedicated educational programs in BMHI at the level of bachelor's, master's, and doctoral degrees. These are the mainstream academic programs in BMHI. In addition, recommendations for continuing education, certification, and accreditation procedures are provided.

CONCLUSION

The IMIA recommendations reflect societal changes related to globalization, digitalization, and digital transformation in general and in healthcare specifically, and center on educational needs for the healthcare workforce, computer scientists, and decision makers to acquire BMHI knowledge and skills at various levels. To support education in BMHI, IMIA offers accreditation of quality BMHI education programs. It supports information exchange on programs and courses in BMHI through its Working Group on Health and Medical Informatics Education.

Leveraging mHealth usage logs to inform health worker performance in a Resource-Limited setting: Case example of mUzima use for a chronic disease program in Western Kenya

BACKGROUND

Health systems in low- and middle-income countries (LMICs) can be strengthened when quality information on health worker performance is readily available. With increasing adoption of mobile health (mHealth) technologies in LMICs, there is an opportunity to improve work-performance and supportive supervision of workers. The objective of this study was to evaluate usefulness of mHealth usage logs (paradata) to inform health worker performance.

METHODOLOGY

This study was conducted at a chronic disease program in Kenya. It involved 23 health providers serving 89 facilities and 24 community-based groups. Study participants, who already used an mHealth application (mUzima) during clinical care, were consented and equipped with an enhanced version of the application that captured usage logs. Three months of log data were used to determine work performance metrics, including: (a) number of patients seen; (b) days worked; (c) work hours; and (d) length of patient encounters.

PRINCIPAL FINDINGS

Pearson correlation coefficient for days worked per participant as derived from logs as well as from records in the Electronic Medical Record system showed a strong positive correlation between the two data sources (r(11) = .92, p < .0005), indicating mUzima logs could be relied upon for analyses. Over the study period, only 13 (56.3%) participants used mUzima in 2,497 clinical encounters. 563 (22.5%) of encounters were entered outside of regular work hours, with five health providers working on weekends. On average, 14.5 (range 1-53) patients were seen per day by providers.

CONCLUSIONS / SIGNIFICANCE

mHealth-derived usage logs can reliably inform work patterns and augment supervision mechanisms made particularly challenging during the COVID-19 pandemic. Derived metrics highlight variabilities in work performance between providers. Log data also highlight areas of suboptimal use, of the application, such as for retrospective data entry for an application meant for use during the patient encounter to best leverage built-in clinical decision support functionality.

Data Cleaning Process for mHealth Log Data to Inform Health Worker Performance

Log data, captured during use of mobile health (mHealth) applications by health providers, can play an important role in informing nature of user engagement with the application. The log data can also be employed in understanding health provider work patterns and performance. However, given that these logs are raw data, they require robust cleaning and curation if accurate conclusions are to be derived from analyzing them. This paper describes a systematic data cleaning process for mHealth-derived logs based on Broeck's framework, which involves iterative screening, diagnosis, and treatment of the log data. For this study, log data from the demonstrative mUzima mHealth application are used. The employed data cleaning process uncovered data inconsistencies, duplicate logs, missing data within logs that required imputation, among other issues. After the data cleaning process, only 39,229 log records out of the initial 91,432 usage logs (42.9%) could be included in the final dataset suitable for analyses of health provider work patterns. This work highlights the significance of having a systematic data cleaning approach for log data to derive useful information on health provider work patterns and performance.

Developing Harmonized Benchmarks for the Master of Science in Health Informatics for the East African Region

Higher education institutions in low- and middle-income countries are increasingly offering post-graduate degree programmes in health informatics. An analysis of accredited Master of Science in Health Informatics (MSc HI) programmes in the East African Community (EAC), a common higher education and labor zone, revealed wide variability in covered courses and competencies. In this paper, we describe the process undertaken to harmonize and establish common benchmarks for MSc HI for the EAC, in collaboration with the Inter-University Council for East Africa (IUCEA). After a multi-step process involving desk-reviews, benchmarking workshop with stakeholders, and quality assurance of benchmarks by IUCEA, the MSc HI benchmarks were finalized. These benchmarks outline the MSc HI degree programme goal, objectives, admission criteria, graduation requirements, and expected Learning Outcomes (ELOs). The ELOs are further translated into courses covering all identified skills and competencies. The benchmarks should facilitate mobility of students, faculty and labor, and improve program quality.

Users' perception on factors contributing to electronic medical records systems use: a focus group discussion study in healthcare facilities setting in Kenya

Background

Electronic medical records systems (EMRs) adoption in healthcare to facilitate work processes have become common in many countries. Although EMRs are associated with quality patient care, patient safety, and cost reduction, their adoption rates are comparatively low. Understanding factors associated with the use of the implemented EMRs are critical for advancing successful implementations and scale-up sustainable initiatives. The aim of this study was to explore end users’ perceptions and experiences on factors facilitating and hindering EMRs use in healthcare facilities in Kenya, a low- and middle-income country.

Methods

Two focus group discussions were conducted with EMRs users (n = 20) each representing a healthcare facility determined by the performance of the EMRs implementation. Content analysis was performed on the transcribed data and relevant themes derived.

Results

Six thematic categories for both facilitators and barriers emerged, and these related to (1) system functionalities; (2) training; (3) technical support; (4) human factors; (5) infrastructure, and (6) EMRs operation mode. The identified facilitators included: easiness of use and learning of the system complemented by EMRs upgrades, efficiency of EMRs in patient data management, responsive information technology (IT) and collegial support, and user training. The identified barriers included: frequent power blackouts, inadequate computers, retrospective data entry EMRs operation mode, lack of continuous training on system upgrades, and delayed IT support.

Conclusions

Users generally believed that the EMRs improved the work process, with multiple factors identified as facilitators and barriers to their use. Most users perceived system functionalities and training as motivators to EMRs use, while infrastructural issues posed as the greatest barrier. No specific EMRs use facilitators and/or barriers could be attributed to facility performance levels. Continuous evaluations are necessary to assess improvements of the identified factors as well as determine emerging issues.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01737-x.

A multivariate statistical evaluation of actual use of electronic health record systems implementations in Kenya

Background

Health facilities in developing countries are increasingly adopting Electronic Health Records systems (EHRs) to support healthcare processes. However, only limited studies are available that assess the actual use of the EHRs once adopted in these settings. We assessed the state of the 376 KenyaEMR system (national EHRs) implementations in healthcare facilities offering HIV services in Kenya.

Methods

The study focused on seven EHRs use indicators. Six of the seven indicators were programmed and packaged into a query script for execution within each KenyaEMR system (KeEMRs) implementation to collect monthly server-log data for each indicator for the period 2012–2019. The indicators included: Staff system use, observations (clinical data volume), data exchange, standardized terminologies, patient identification, and automatic reports. The seventh indicator (EHR variable Completeness) was derived from routine data quality report within the EHRs. Data were analysed using descriptive statistics, and multiple linear regression analysis was used to examine how individual facility characteristics affected the use of the system.

Results

213 facilities spanning 19 counties participated in the study. The mean number of authorized users who actively used the KeEMRs was 18.1% (SD = 13.1%, p<0.001) across the facilities. On average, the volume of clinical data (observations) captured in the EHRs was 3363 (SD = 4259). Only a few facilities(14.1%) had health data exchange capability. 97.6% of EHRs concept dictionary terms mapped to standardized terminologies such as CIEL. Within the facility EHRs, only 50.5% (SD = 35.4%, p< 0.001) of patients had the nationally-endorsed patient identifier number recorded. Multiple regression analysis indicated the need for improvement on the mode of EHRs use of implementation.

Conclusion

The standard EHRs use indicators can effectively measure EHRs use and consequently determine success of the EHRs implementations. The results suggest that most of the EHRs use areas assessed need improvement, especially in relation to active usage of the system and data exchange readiness.

Comparative analysis of competency coverage within accredited master's in health informatics programs in the East African region

OBJECTIVE

As master of science in health informatics (MSc HI) programs emerge in developing countries, quality assurance of these programs is essential. This article describes a comprehensive comparative analysis of competencies covered by accredited MSc HI programs in the East African common labor and educational zone.

MATERIALS AND METHODS

Two reviewers independently reviewed curricula from 7 of 8 accredited MSc HI university programs. The reviewers extracted covered competencies, coding these based on a template that contained 73 competencies derived from competencies recommended by the International Medical Informatics Association, plus additional unique competencies contained within the MSc HI programs. Descriptive statistics were used to summarize the structure and completion requirements of each MSc HI program. Jaccard similarity coefficient was used to compare similarities in competency coverage between universities.

RESULTS

The total number of courses within the MSc HI degree programs ranged from 8 to 22, with 35 to 180 credit hours. Cohen's kappa for coding competencies was 0.738. The difference in competency coverage was statistically significant across the 7 institutions (P = .012), with covered competencies across institutions ranging from 32 (43.8%) to 49 (67.1%) of 73. Only 4 (19%) of 21 university pairs met a cutoff of over 70% similarity in shared competencies.

DISCUSSION

Significant variations observed in competency coverage within MSc HI degree programs could limit mobility of student, faculty, and labor.

CONCLUSIONS

Comparative analysis of MSc HI degree programs across 7 universities in East Africa revealed significant differences in the competencies that were covered.

Acceptability, Barriers and Facilitators of Mobile Text Message Reminder System Implementation in Improving Child Vaccination: A Qualitative Study in Northwest Ethiopia

Background

Mobile phone text message-based mHealth interventions have shown promise in improving health service delivery. Despite the promising findings at a small scale and few contexts, implementing new technologies as part of changes to health care services is inherently challenging. Though there is a potential to introduce mHealth initiatives to health systems of developing countries, existing evidence on the barriers and facilitators of implementation in different contexts is not adequate. Therefore, this study aimed to explore the acceptability, barriers and facilitators of implementing mobile text message reminder system for child vaccination in Ethiopia.

Methods

This study applied a phenomenological study design. The study was conducted in north-west, Ethiopia between July 28 and August 19, 2020. A total of 23 participants were purposively selected for the in-depth and key informant interviews. We used an interview guide to collect data and audio-records of interviews were transcribed verbatim. Coding was done to identify patterns and thematic analysis was conducted using ATLAS ti7 software.

Results

The findings indicated that mothers were receptive to mobile text message reminders for their child’s vaccination. Low mobile phone ownership, access to mobile network, access to electricity and illiteracy among the target population were identified as barriers that would affect implementation. Confidentiality and security-related issues are not barriers to implementation of text message reminders for child vaccination service. Facilitators for implementation include stakeholder collaboration, providing orientation/training to users, and willingness to pay by clients.

Conclusion

In this study, using mobile phone text message reminders for child vaccination services are acceptable by clients. Barriers identified were related to inadequate ICT infrastructure and other technical issues. Addressing the potential barriers and leveraging the existing opportunities could optimize the implementation in resource-limited settings. Before actual implementation, program implementers should also consider providing orientation to users on the proposed mHealth program.

Mothers intention and preference to use mobile phone text message reminders for child vaccination in Northwest Ethiopia

OBJECTIVES

With the unprecedented penetration of mobile devices in the developing world, mHealth applications are being leveraged for different health domains. Among the different factors that affect the use of mHealth interventions is the intention and preference of end-users to use the system. This study aimed to assess mother's intention and preference to use text message reminders for vaccination in Ethiopia.

METHODS

A cross-sectional study was conducted among 460 mothers selected through a systematic random sampling technique. Initially, descriptive statistics were computed. Binary logistic regression analysis was also used to assess factors associated with the outcome variable.

RESULTS

In this study, of the 456 mothers included for analysis, 360 (78.9%) of mothers have intention to use text message reminders for vaccination. Of these, 270 (75%) wanted to receive the reminders a day before the vaccination due date. Mothers aged 35 years or more (AOR=0.35; 95% CI: 0.15 to 0.83), secondary education and above (AOR=4.43; 95% CI: 2.05 to 9.58), duration of mobile phone use (AOR=3.63; 95% CI: 1.66 to 7.94), perceived usefulness (AOR=6.37; 95% CI: 3.13 to 12.98) and perceived ease of use (AOR=3.85; 95% CI: 2.06 to 7.18) were predictors of intention to use text messages for vaccination.

CONCLUSION

In conclusion, majority of mothers have the intention to use text message reminders for child vaccination. Mother's age, education, duration of mobile phone use, perceived usefulness and perceived ease of use were associated with intention of mothers to use text messages for vaccination. Considering these predictors and user's preferences before developing and testing text message reminder systems is recommended.

A systematic approach to equity assessment for digital health interventions: case example of mobile personal health records

Despite the increasing number of digital health interventions in low- and middle-income countries and other low-resource settings, little attention has been paid to systematically evaluating impacts of these interventions on health equity. In this article, we present a systematic approach for assessing equity impacts of digital health interventions modeled after the Health Equity Impact Assessment of the Ontario Ministry of Health and Long-Term Care. The assessment approach has 4 steps that address (1) scope, (2) potential equity impacts, (3) mitigation, (4) monitoring, and (5) dissemination strategies. The approach examines impacts on vulnerable and marginalized populations and considers various social determinants of health. Equity principles outlined by Whitehead and Dahlgren are used to ensure systematic considerations of all potential equity impacts. The digital health evaluation approach that is presented is applied to a case example of mobile personal health record application in Kenya.

Development of standard indicators to assess use of electronic health record systems implemented in low-and medium-income countries

Background

Electronic Health Record Systems (EHRs) are being rolled out nationally in many low- and middle-income countries (LMICs) yet assessing actual system usage remains a challenge. We employed a nominal group technique (NGT) process to systematically develop high-quality indicators for evaluating actual usage of EHRs in LMICs.

Methods

An initial set of 14 candidate indicators were developed by the study team adapting the Human Immunodeficiency Virus (HIV) Monitoring, Evaluation, and Reporting indicators format. A multidisciplinary team of 10 experts was convened in a two-day NGT workshop in Kenya to systematically evaluate, rate (using Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART) criteria), prioritize, refine, and identify new indicators. NGT steps included introduction to candidate indicators, silent indicator ranking, round-robin indicator rating, and silent generation of new indicators. 5-point Likert scale was used in rating the candidate indicators against the SMART components.

Results

Candidate indicators were rated highly on SMART criteria (4.05/5). NGT participants settled on 15 final indicators, categorized as system use (4); data quality (3), system interoperability (3), and reporting (5). Data entry statistics, systems uptime, and EHRs variable concordance indicators were rated highest.

Conclusion

This study describes a systematic approach to develop and validate quality indicators for determining EHRs use and provides LMICs with a multidimensional tool for assessing success of EHRs implementations.

PEERNaija: A Gamified mHealth Behavioral Intervention to Improve Adherence to Antiretroviral Treatment Among Adolescents and Young Adults in Nigeria

Background: HIV is the leading cause of death for youth in Sub-Saharan Africa (SSA). The rapid proliferation of smart phones in SSA provides an opportunity to leverage novel approaches to promote adherence to life-saving antiretroviral therapy (ART) for adolescents and young adults living with HIV (AYA-HIV) that go beyond simple medication reminders.

Methods: Guided by the Integrate, Design, Assess and Share (IDEAS) framework, our multidisciplinary team developed a peer-based mHealth ART adherence intervention—PEERNaija. Grounded in Social Cognitive Theory, and principles of contingency management and supportive accountability, PEERNaija delivers a multi-faceted behavioral intervention within a smartphone application to address important obstacles to adherence.

Results:PEERNaija was developed as a gamified Android-based mHealth application to support the behavioral change goal of improving ART adherence among AYA-HIV within Nigeria, a low- and middle- income country (LMIC). Identified via foundational interviews with the target population and review of the literature, key individual (forgetfulness and poor executive functioning), environmental (poor social support) and structural (indirect cost of clinic-based interventions) barriers to ART adherence for AYA-HIV informed application features. Further informed by established behavioral theories and principles, the intervention aimed to improve self-efficacy and self-regulation of AYA-HIV, leverage peer relationships among AYA to incentivize medication adherence (via contingency management, social accountability), provide peer social support through an app-based chat group, and allow for outreach of the provider team through the incorporation of a provider application. Gamification mechanics incorporated within PEERNaija include: points, progress bar, leaderboard with levels, achievements, badges, avatars and targeted behavior change messages. PEERNaija was designed as a tethered mobile personal health record application, sharing data to the widely deployed OpenMRS electronic health record application. It also uses the secure opensource Nakama gamification platform, in line with Principles of Digital Development that emphasize use of opensource systems within LMICs.

Conclusions: Theory-based gamified mHealth applications that incorporate social incentives have the potential to improve adherence to AYA-HIV. Ongoing evaluations of PEERNaija will provide important data for the potential role for a gamified, smartphones application to deliver multifaceted adherence interventions for vulnerable AYA-HIV in SSA.

Coverage of IMIA-recommended Competencies by Masters in Health Informatics Degree Programs in East Africa

OBJECTIVE

The International Medical Informatics Association (IMIA) has provided recommendations on Education in Biomedical and Health Informatics (BMHI) as guidance on competencies relevant to education of BMHI specialists. However, it remains unclear how well these competencies have been adopted to guide emerging degree programs in low- and middle-income countries (LMICs). We evaluated comprehensiveness of IMIA-recommended competency coverage by Masters in Health Informatics (MSc HI) programs in East Africa.

MATERIALS AND METHODS

Two investigators independently reviewed curricula for seven accredited MSc HI university programs in the East Africa region to extract covered competencies using an instrument based on the IMIA education recommendations. Descriptive statistics were used to determine competency coverage by institution and across institutions and by IMIA-defined competency domains. Duplication of competency coverage in courses within each curriculum was also evaluated. Multivariable logistic regression was used to test whether coverage of IMIA-recommended competencies differed between institutions.

RESULTS

Cohen's Kappa for coding competencies within courses was 0.738 (95% CI, 0.713-0.764). Coverage of the 40 recommended required IMIA competencies by institutional curricula ranged from 25 (62.5%) to 39 (97.5%) (p < 0.0001), with only 18 (45%) of these competencies covered by all seven institutions. No significant variations in competency coverage were observed between the domains of information sciences (83.7%), health sciences (71.4%), and core BMHI competencies (83.5%) (p = 0.13). On average, each competency was covered by 3.06 courses in each curriculum (range 0 - 14). Curricula also contained 25 additional competencies not part of the IMIA recommendations, 15 of which were found only within the curriculum of a single institution.

DISCUSSION

There is significant variability in coverage of IMIA-recommended competencies across MSc HI curricula evaluated, with observed duplication of competency coverage within each curriculum. The additional competencies uncovered that were not part of the IMIA-recommendations were not universally shared across institutions.

CONCLUSION

The IMIA education recommendations provide a relevant, comprehensive reference guide for developing and improving health informatics degree programs within LMIC settings. Variability in competency coverage needs to be addressed for institutions within similar educational and labor regions.

Health Facility Ownership Type and Performance on HIV Indicator Data Reporting in Kenya

In low- and middle-income countries, private and public facilities tend to have highly variable characteristics, which might affect their performance in meeting reporting requirements mandated by ministries of health. There is conflicting evidence on which facility type performs better across various care dimensions, and only few studies exist to evaluate relative performance around nationally-mandated indicator reporting to Ministries of Health. In this study, we evaluated the relationship between facility ownership type and performance on HIV indicator data reporting, using the case of Kenya. We conducted Mann-Whitney U tests using HIV indicator data extracted from years 2011 to 2018 for all the counties in Kenya, from the District Health Information Software 2 (DHIS2). Results from the study reveal that public facilities have statistically significant better performance compared to private facilities, with an exception of year 2017 in reporting of counselling and testing, and prevention of mother-to-child transmission indicator categories.

K-Means Clustering in Monitoring Facility Reporting of HIV Indicator Data: Case of Kenya

Health management information systems (HMISs) in low- and middle-income countries have been used to collect large amounts of data after years of implementation, especially in support of HIV care services. National-level aggregate reporting data derived from HMISs are essential for informed decision-making. However, the optimal statistical approaches and algorithms for deriving key insights from these data are yet to be fully and adequately utilized. This paper demonstrates use of the k-means clustering algorithm as an approach in supporting monitoring of facility reporting and data-informed decision-making, using the case example of Kenya HIV national reporting data. Results reveal four homogeneous cluster categories that can be used in assessing overall facility performance and rating of that performance.

Assessment of HIV Data Reporting Performance by Facilities During EMR Systems Implementations in Kenya

There is little evidence that implementations of Electronic Medical Record Systems (EMRs) are associated with better reporting completeness and timeliness of HIV routine data to the national aggregate system. We analyzed the reporting completeness and timeliness of HIV reports to Kenya's national aggregate reporting system from District Health Information Software 2 (DHIS2) for the period 2011 to 2018. On average, reporting completeness improved to 97% whilst timeliness increased to 83% in 2017 with similar performance for the facilities under study that implemented either KenyaEMR or IQCare. However, in 2018, the reporting rates dropped by 13% for completeness and 11% for timeliness most likely due to changed reporting procedures. This suggests that besides EMRs, there are other factors influencing reporting such as reporting routines, which need to be assessed separately. Nonetheless, the EMRs have facilitated the collection of HIV data for submission to the DHIS2, which in turn facilitates the reporting process for the data officers.

mHealth spectroscopy of blood hemoglobin with spectral super-resolution

Although blood hemoglobin (Hgb) testing is a routine procedure in a variety of clinical situations, noninvasive, continuous, and real-time blood Hgb measurements are still challenging. Optical spectroscopy can offer noninvasive blood Hgb quantification, but requires bulky optical components that intrinsically limit the development of mobile health (mHealth) technologies. Here, we report spectral super-resolution (SSR) spectroscopy that virtually transforms the built-in camera (RGB sensor) of a smartphone into a hyperspectral imager for accurate and precise blood Hgb analyses. Statistical learning of SSR enables us to reconstruct detailed spectra from three color RGB data. Peripheral tissue imaging with a mobile application is further combined to compute exact blood Hgb content without a priori personalized calibration. Measurements over a wide range of blood Hgb values show reliable performance of SSR blood Hgb quantification. Given that SSR does not require additional hardware accessories, the mobility, simplicity, and affordability of conventional smartphones support the idea that SSR blood Hgb measurements can be used as an mHealth method.

Performance of an open source facial recognition system for unique patient matching in a resource-limited setting

BACKGROUND

The lack of unique patient identifiers is a challenge to patient care in developing countries. Probabilistic and deterministic matching approaches remain sub-optimal. However, affordable and scalable biometric solutions have not been rigorously evaluated in these settings.

METHODS

We implemented and evaluated performance of an open-source facial recognition system, OpenFace, integrated within a nationally-endorsed electronic health record system in Western Kenya. Patients were first enrolled via facial images, and later matched via the system. Accuracy of facial recognition was evaluated using Sensitivity; False Acceptance Rate (FAR); False Rejection Rate (FRR); Failure to Capture Rate (FTC) and Failure to Enroll Rate (FTE). 103 patients (mean age 37.8, 49.5% female) were enrolled.

RESULTS

The system had a sensitivity of 99.0%, FAR <1%, FRR 0.00, FTC 0.00 and FTE 0.00. Wearing spectacles did not affect performance.

CONCLUSION

An open source facial recognition system correctly and accurately identified almost all patients during the first match.

Timely completion of vaccination and its determinants among children in northwest, Ethiopia: a multilevel analysis

BACKGROUND

Timely vaccination is key to prevent unnecessary childhood mortality from vaccine-preventable diseases. Despite the substantial efforts to improve vaccination completeness, the effort towards timeliness of vaccination is limited with non-attendance and delays to vaccination appointments remaining a big challenge in developing countries. There is also a limited evidence on timeliness of vaccination. Therefore, this study aimed to determine the magnitude and associated factors for timely completion of vaccination among children in Gondar city administration, north-west, Ethiopia.

METHOD

This study employed a community-based cross sectional study design. A sample size of 821 children aged 12 to 23 months were considered. Two stages random sampling technique was used to select study subjects. To account the effect of clustering, bivariable and multivariable multilevel logistic regression analysis were applied. The measures of association estimates were expressed as adjusted odds ratio (AOR) with their 95% confidence intervals (CIs).

RESULTS

Of the 774 children included for analysis, 498 (64.3%) were fully vaccinated while 247 (31.9%) were fully vaccinated on-time. Caregivers who had secondary education and above (AOR = 2.391; 95% CI: 1.317-4.343), from richest households (AOR = 2.381; 95% CI: 1.502-3.773), children whose mother attended four or more ante natal care visits (AOR = 2.844; 95% CI: 1.310-6.174) and whose mother had two or more post natal care visits (AOR = 2.054; 95%CI:1.377-3.063) were positively associated with on-time full vaccination. In contrary, caregivers aged above 35 years (AOR = 0.469; 95 % CI: 0.253-0.869], being vaccinated at health post (AOR = 0.144; 95%CI: 0.048-0.428) and travelling more than 30 min to the vaccination site (AOR = 0.158; 95%CI: 0.033-0.739) were negatively associated with on-time full vaccination. The random effects indicated that 26% of the variability in on-time full vaccination was attributable to differences between communities.

CONCLUSION

In this study, untimely vaccination was found to be high. Different individual and contextual factors were found to be associated with on-time full vaccination. Therefore, tailored strategies have to be designed and implemented to address people and the communities where they live. Moreover, timeliness of vaccination should be considered as important indicator of the immunization program performance in Ethiopia.

Therapeutic turnaround times for common laboratory tests in a tertiary hospital in Kenya

METHODS

We evaluated therapeutic TAT for a tertiary hospital in Western Kenya, using a time-motion study focusing specifically on common hematology and biochemistry orders. The aim was to determine significant bottlenecks in diagnostic testing processes at the institution.

RESULTS

A total of 356 (155 hematology and 201 biochemistry) laboratory tests were fully tracked from the time of ordering to availability of results to care providers. The total therapeutic TAT for all tests was 21.5 ± 0.249 hours (95% CI). The therapeutic TAT for hematology was 20.3 ± 0.331 hours (95% CI) while that for biochemistry tests was 22.2 ± 0.346 hours (95% CI). Printing, sorting and dispatch of the printed results emerged as the most significant bottlenecks, accounting for up to 8 hours of delay (Hematology-8.3 ± 1.29 hours (95% CI), Biochemistry-8.5 ± 1.18 hours (95% CI)). Time of test orders affected TAT, with orders made early in the morning and those in the afternoon experiencing the most delays in TAT.

CONCLUSION

Significant inefficiencies exist at multiple steps in the turnaround times for routine laboratory tests at a large referral hospital within an LMIC setting. Multiple opportunities exist to improve TAT and streamline processes around diagnostic testing in this and other similar settings.

Community Health Workers Improve Linkage to Hypertension Care in Western Kenya

BACKGROUND

Elevated blood pressure (BP) is the leading global risk factor for mortality. Delay in seeking hypertension care is associated with increased mortality.

OBJECTIVES

This study investigated whether community health workers, equipped with behavioral communication strategies and smartphone technology, can increase linkage of individuals with elevated BP to a hypertension care program in western Kenya and significantly reduce BP.

METHODS

The study was a cluster randomized trial with 3 arms: 1) usual care (standard training); 2) "paper-based" (tailored behavioral communication, using paper-based tools); and 3) "smartphone" (tailored behavioral communication, using smartphone technology). The co-primary outcomes were: 1) linkage to care; and 2) change in systolic BP (SBP). A covariate-adjusted mixed-effects model was used, adjusting for differential time to follow-up. Bootstrap and multiple imputation were used to handle missing data.

RESULTS

A total of 1,460 individuals (58% women) were enrolled (491 usual care, 500 paper-based, 469 smartphone). Average baseline SBP was 159.4 mm Hg. Follow-up measures of linkage were available for 1,128 (77%) and BP for 1,106 (76%). Linkage to care was 49% overall, with significantly greater linkage in the usual care and smartphone arms of the trial. Average overall follow-up SBP was 149.9 mm Hg. Participants in the smartphone arm experienced a modestly greater reduction in SBP versus usual care (-13.1 mm Hg vs. -9.7 mm Hg), but this difference was not statistically significant. Mediation analysis revealed that linkage to care contributed to SBP change.

CONCLUSIONS

A strategy combining tailored behavioral communication and mobile health (mHealth) for community health workers led to improved linkage to care, but not statistically significant improvement in SBP reduction. Further innovations to improve hypertension control are needed. (Optimizing Linkage and Retention to Hypertension Care in Rural Kenya [LARK]; NCT01844596).

A Model Driven Approach to the Design of a Gamified e-Learning System for Clinical Guidelines

Clinical practice guidelines (CPGs) are indispensable in the practice of evidence-based medicine. However, the cost of effective CPG dissemination strategies is prohibitive and not cost-effective. Therefore, scalable strategies using available technology are needed. We describe a formal model-driven approach to design a gamified e-learning system for clinical guidelines. We employ gamification to increase user motivation and engagement in the training of guideline content. Our approach involves the use of models for different aspects of the system, an entity model for the clinical domain, a workflow model for the clinical processes and a game model to manage the training sessions. A game engine instantiates a training session by coupling the workflow and entity models to automatically generate questions based on the data in the model instances. Our approach is flexible and adaptive as it allows for easy updates of the guidelines, integration with different device interfaces and representation of any guideline.

Development and Usability of Mobile-based Healthcare Protocols in Kenya

Healthcare protocols have been shown to improve the quality of health service delivery by offering explicit guidelines and recommendations for clinicians who are uncertain about how to proceed in a given clinical situation. While various modalities are used to implement protocols, few rigorous evaluations of protocol use exist in low-resource clinical settings. This study aimed to develop mobile-based protocols (MBPs) and test their usability against currently used paper-based protocol (PBPs). Satisfaction, efficiency and effectiveness of the protocols were evaluated through a think-aloud usability exercise, in-depth interviews, and through a questionnaire. Compared to PBPs, satisfaction scores were higher with MBPs (83.8 versus 66.8, p=0.0498), number of errors lower with MBPs (2/25 versus 5/25, p=0.1089), with average time for task completion higher with MBPs (23.3s versus21.6s, p=0.7394). MBPs offer more satisfaction and trend towards being more effective as a dissemination modality for healthcare protocols in low-resource settings.

Implementation of USSD Technology to Improve Quality of Routinely Reported Health Data in a Resource-Limited Setting

Health decision-making is heavily premised on routinely reported data from lower levels of healthcare delivery to the national level. The reported data are of best use if their quality is high. Unfortunately, in many resource-limited settings in sub-Saharan Africa, the quality of reported data is often poor. Among the reasons attributed for poor data quality is use of sub-optimal modalities for collecting and transmitting data, such as paper-based and Short Message Service (SMS). Through a user-centered approach, we developed and implemented an Unstructured Supplementary Service Data (USSD)-based health data reporting intervention in a district in Uganda. The impact of the developed system on report accuracy, timeliness and completeness was evaluated against the expected 100% rates by the Ministry of Health (MoH). A total of 224 reports were submitted over the two-month study period. Of the submitted reports, 171 (76.3%) were complete (p<0.0001) compared to MoH's required 100%). 161 (71.9%) were accurate (P<0.0001), and 158 (70.5%) of the reports were submitted on time (p<0.0001). The deficiencies were largely attributed to a few facilities, as only 17.9% of facilities had data discrepancies with a mean of - 2.11 (P=0.38), 96.4% (0.130) of the facilities had complete reports and 87.4% (0.100) of the facilities reported on time. Poor network coverage was an outstanding challenge to reporting.

Effect of mobile text message reminders on routine childhood vaccination: a systematic review and meta-analysis

BACKGROUND

The World Health Organization estimates that 29% of under-five mortality could be prevented with existing vaccines. However, non-consistent attendance for immunization appointments remains a global challenge to healthcare providers. Thus, innovative strategies are required to reach the last mile where technology could be effectively utilized to achieve better compliance with children immunization schedules. Therefore, the aim of the review was to systematically collect and summarize the available evidence on the effectiveness of text message reminders on childhood vaccination.

METHODS

This review was conducted according to a priori published protocol on PROSPERO. A systematic literature search of databases (PubMed/MEDLINE, EMBASE, Cochrane/Wiley library, and Science direct) was conducted. Eligibility and risk of bias assessments were performed independently by two reviewers. PRISMA flow diagrams were used to summarize the study selection process. Taking into account the level of heterogeneity, a random effects model was used and risk ratios with their 95% CI were used to present the pooled estimates. To investigate the sources of heterogeneity, subgroup analysis and meta-regression analysis were also considered. In this review, publication bias was assessed statistically using Harbord test.

RESULTS

A total of 1771 articles were searched. Out of those 1771 articles, 558 duplicated articles were removed. About 1213 articles were further screened, and finally, ten articles met the inclusion criteria. The meta-analysis showed that there is a significant effect of text message reminders on childhood vaccination coverage (RR = 1.11; 95% CI 1.05-1.17) with a moderate level of heterogeneity (I² = 64.3%, P = 0.003). The results from the Harbord test suggested that there is no evidence for publication bias (P = 0.340).

CONCLUSION

This review highlights the potential benefits of incorporating mobile text message reminders into the standard management of childhood immunizations, especially in low- and middle-income countries. The frequency and timing of the text message reminders are also crucial in determining the effectiveness of text message reminders. Hence, mHealth interventions deserve more attention as a potential innovation to improve healthcare programs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017074230.

Ethical issues in the use of SMS messaging in HIV care and treatment in low- and middle-income countries: case examples from Mozambique

The introduction of mobile communication technologies in health care in low- and middle-income countries offers an opportunity for increased efficiencies in provision of care, improved utilization of scarce resources, reductions in workload, and increased reach of services to a larger target population. Short message service (SMS) technologies offer promise, with several large-scale SMS-based implementations already under way. Still largely lacking in the research literature are evaluations of specific ethical issues that arise when SMS programs are implemented and studied in resource-limited settings. In this paper, we examine the ethical issues raised by the deployment of SMS messaging to support patient retention in HIV care and treatment and in the research conducted to evaluate that deployment. We use case studies that are based in Mozambique and ground our discussion in the ethical framework for international research proposed by Emanuel et al., highlighting ethical considerations needed to guide the design and implementation of future SMS-based interventions. Such guidance is increasingly needed in countries such as Mozambique, where the local capacity for ethical study design and oversight is still limited and the scale-up and study of mHealth initiatives are still driven predominantly by international collaborators. These issues can be complex and will need ongoing attention on a case-by-case basis to ensure that appropriate protections are in place, while simultaneously maximizing the potential benefit of new mHealth technologies.

Smartphone usage and preferences among postpartum HIV-positive women in South Africa

In South Africa, HIV-positive women receiving antiretroviral therapy often are lost to care postpartum; strategies to support long-term engagement are needed. Mobile health (mHealth) interventions are emerging as a possible solution for supporting long-term engagement in the prevention of mother-to-child transmission (PMTCT) of HIV care continuum. In order to explore acceptability and feasibility of mobile health (mHealth) interventions in this context, we conducted focus group discussions (FGDs) to assess trends in smartphone usage in postpartum women. In six FGDs, we interviewed 27 HIV-positive, postpartum women who attended regular care at the Gugulethu Community Health Centre in Cape Town, South Africa, and who use a smartphone. Questions assessed the respondent's general trends in smartphone use, as well as their exposure to and perceptions of mHealth interventions. We found little turnover in phones and phone numbers, and about half the participants shared their devices with family and friends. Respondents reported high familiarity with smartphone applications, including WhatsApp, Facebook, YouTube, and Twitter, with WhatsApp as their preferred method of smartphone communication. Data bundles were most often used to connect to the internet, motivated by the perception that data bundles last longer and are cheaper than airtime, but respondents were adept at locating Wi-Fi sources at work or other public spaces. Nearly all participants were familiar with MomConnect, a national mHealth text support service in South Africa, and most described it positively. Respondents expressed interest in future HIV mHealth applications including complementary health information on physical activity, nutrition, mental health and basic social services. Participants were active and engaged smartphone users with reliable internet connections and a positive attitude towards mHealth platforms. Future mHealth interventions show promise in this population.

Facilitators and Barriers of Electronic Medical Records Systems Implementation in Low Resource Settings: A Holistic View

Electronic Medical Records (EMR) systems show promise for facilitating health care improvement in quality patient care, patient safety and cost reduction. Nevertheless, their adoption requires careful planning and execution for successful implementation and optimal benefits. The main objective of this review was to identify, analyse and categorize facilitators and barriers to the implementation of EMRs in resource constrained settings in order to gain insight for successful EMR implementation. A literature review on papers from 2007 to 2017 concerning facilitators and barriers to EMRs implementation was conducted. The study included 18 articles that met selection criteria. Four categories of facilitators and barriers including a total of 28 sub-categories were identified from content analysis. These are technical, human, processes and organizational. EMR implementers should pay attention to these issues and adopt a change management strategy for sustainable EMR use in resource-constrained settings.

A Review of Current Patient Matching Techniques

As healthcare organizations strive to improve quality of care and patient safety, it becomes paramount that they identify patients correctly and match records accurately both within and across institutions. Continuous care and population health benefits can be optimized when providers can have a comprehensive view of a patient's health record through seamless health information exchange. Various patient matching techniques have emerged to facilitate accurate patient identification. In this paper, we present a review of existing patient matching techniques, analyzed based on accuracy, cost and execution time.

Comparative Performance Analysis of Different Fingerprint Biometric Scanners for Patient Matching

Unique patient identification within health services is an operational challenge in healthcare settings. Use of key identifiers, such as patient names, hospital identification numbers, national ID, and birth date are often inadequate for ensuring unique patient identification. In addition approximate string comparator algorithms, such as distance-based algorithms, have proven suboptimal for improving patient matching, especially in low-resource settings. Biometric approaches may improve unique patient identification. However, before implementing the technology in a given setting, such as health care, the right scanners should be rigorously tested to identify an optimal package for the implementation. This study aimed to investigate the effects of factors such as resolution, template size, and scan capture area on the matching performance of different fingerprint scanners for use within health care settings. Performance analysis of eight different scanners was tested using the demo application distributed as part of the Neurotech Verifinger SDK 6.0.

Setting the Agenda for Personal Health Records in Low- and Middle-Income Countries

In the developed world, Personal Health Records (PHRs) have been demonstrated to improve patient adherence, reduce medical errors, improve patient-provider communication, improve chronic disease management, and promote behavior change. PHRs have not been widely adopted in low- and middle-income countries. There is rising use of smartphones, adoption of national-level electronic health systems, and change in historical perceptions on acceptance of technology. It is thus an opportune time to critically examine the potential role and approaches to PHRs in LMICs.

Ethical Issues in Implementing National-Level Health Data Warehouses in Developing Countries

National Health Data Warehouses (NHDWHs) promise to improve individual and population health. These systems are now increasingly being deployed in low- and middle-income countries (LMICs), given increased recognition of the value of data analytics in informing decision-making. However, ethical issues relevant to implementation of NHDWHs in LMICs remain largely ignored or, at best, inadequately addressed. In this paper, we highlight and critically analyze several of the key ethical issues, including privacy, informed consent and trust, confidentiality and security, secondary data use, sustainability and implementation validity, risk-benefit ratio, governance and conflict of interest, justice, equity, access, and collaborative partnerships. We then provide a set of guiding principles and points to consider for countries and implementers to guide further decision-making around ethics of implementing NHDWHs within LMICs.

Critical Issues in Evaluating National-Level Health Data Warehouses in LMICs: Kenya Case Study

Low-Middle-Income-Countries (LMICs) are beginning to adopt national health data warehousing (NHDWs) for making strategic decisions and for improving health outcomes. Given the numerous challenges likely to be faced in establishment of NHDWs by LMICs, it is prudent that evaluations are done in relation to the data warehouses (DWs), in order to identify and mitigate critical issues that arise. When critic issues are not identified, DWs are prone to suboptimal implementation with compromised outcomes. Despite the fact that several publications exist on evaluating DWs, evaluations specific to health data warehouses are scanty, with almost none evaluating NHDWs more so in LMICs. This paper uses a systematic approach guided by an evaluation framework to identify critical issues to be considered in evaluating Kenya's NHDW.

Assessing the impact of a primary care electronic medical record system in three Kenyan rural health centers

OBJECTIVE

Efficient, effective health care requires rapid availability of patient information. We designed, implemented, and assessed the impact of a primary care electronic medical record (EMR) in three rural Kenyan health centers.

METHOD

Local clinicians identified data required for primary care and public health reporting. We designed paper encounter forms to capture these data in adult medicine, pediatric, and antenatal clinics. Encounter form data were hand-entered into a new primary care module in an existing EMR serving onsite clinics serving patients infected with the human immunodeficiency virus (HIV). Before subsequent visits, Summary Reports were printed containing selected patient data with reminders for needed HIV care. We assessed effects on patient flow and provider work with time-motion studies before implementation and two years later, and we surveyed providers' satisfaction with the EMR.

RESULTS

Between September 2008 and December 2011, 72 635 primary care patients were registered and 114 480 encounter forms were completed. During 2011, 32 193 unique patients visited primary care clinics, and encounter forms were completed for all visits. Of 1031 (3.2%) who were HIV-infected, 85% received HIV care. Patient clinic time increased from 37 to 81 min/visit after EMR implementation in one health center and 56 to 106 min/visit in the other. However, outpatient visits to both health centers increased by 85%. Three-quarters of increased time was spent waiting. Despite nearly doubling visits, there was no change in clinical officers' work patterns, but the nurses' and the clerks' patient care time decreased after EMR implementation. Providers were generally satisfied with the EMR but desired additional training.

CONCLUSIONS

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.

Usability and feasibility of a tablet-based Decision-Support and Integrated Record-keeping (DESIRE) tool in the nurse management of hypertension in rural western Kenya

BACKGROUND

Mobile health (mHealth) applications have recently proliferated, especially in low- and middle-income countries, complementing task-redistribution strategies with clinical decision support. Relatively few studies address usability and feasibility issues that may impact success or failure of implementation, and few have been conducted for non-communicable diseases such as hypertension.

OBJECTIVE

To conduct iterative usability and feasibility testing of a tablet-based Decision Support and Integrated Record-keeping (DESIRE) tool, a technology intended to assist rural clinicians taking care of hypertension patients at the community level in a resource-limited setting in western Kenya.

METHODS

Usability testing consisted of "think aloud" exercises and "mock patient encounters" with five nurses, as well as one focus group discussion. Feasibility testing consisted of semi-structured interviews of five nurses and two members of the implementation team, and one focus group discussion with nurses. Content analysis was performed using both deductive codes and significant inductive codes. Critical incidents were identified and ranked according to severity. A cause-of-error analysis was used to develop corresponding design change suggestions.

RESULTS

Fifty-seven critical incidents were identified in usability testing, 21 of which were unique. The cause-of-error analysis yielded 23 design change suggestions. Feasibility themes included barriers to implementation along both human and technical axes, facilitators to implementation, provider issues, patient issues and feature requests.

CONCLUSIONS

This participatory, iterative human-centered design process revealed previously unaddressed usability and feasibility issues affecting the implementation of the DESIRE tool in western Kenya. In addition to well-known technical issues, we highlight the importance of human factors that can impact implementation of mHealth interventions.

Building Comprehensive and Sustainable Health Informatics Institutions in Developing Countries: Moi University Experience

Current approaches for capacity building in Health Informatics (HI) in developing countries mostly focus on training, and often rely on support from foreign entities. In this paper, we describe a comprehensive and multidimensional capacity-building framework by Lansang &amp; Dennis, and its application for HI capacity building as implemented in a higher-education institution in Kenya. This framework incorporates training, learning-by-doing, partnerships, and centers of excellence. At Moi University (Kenya), the training dimensions include an accredited Masters in HI Program, PhD in HI, and HI short courses. Learning-by-doing occurs through work within MOH facilities at the AMPATH care and treatment program serving 3 million people. Moi University has formed strategic HI partnerships with Regenstrief Institute, Inc. (USA), University of Bergen (Norway), and Makerere University (Uganda), among others. The University has also created an Institute of Biomedical Informatics to serve as an HI Center of Excellence in the region. This Institute has divisions in Training, Research, Service and Administration. The HI capacity-building approach by Moi provides a model for adoption by other institutions in resource-limited settings.

Developing a National-Level Concept Dictionary for EHR Implementations in Kenya

The increasing adoption of Electronic Health Records (EHR) by developing countries comes with the need to develop common terminology standards to assure semantic interoperability. In Kenya, where the Ministry of Health has rolled out an EHR at 646 sites, several challenges have emerged including variable dictionaries across implementations, inability to easily share data across systems, lack of expertise in dictionary management, lack of central coordination and custody of a terminology service, inadequately defined policies and processes, insufficient infrastructure, among others. A Concept Working Group was constituted to address these challenges. The country settled on a common Kenya data dictionary, initially derived as a subset of the Columbia International eHealth Laboratory (CIEL)/Millennium Villages Project (MVP) dictionary. The initial dictionary scope largely focuses on clinical needs. Processes and policies around dictionary management are being guided by the framework developed by Bakhshi-Raiez et al. Technical and infrastructure-based approaches are also underway to streamline workflow for dictionary management and distribution across implementations. Kenya's approach on comprehensive common dictionary can serve as a model for other countries in similar settings.

Computer-generated reminders and quality of pediatric HIV care in a resource-limited setting

OBJECTIVES

To evaluate the impact of clinician-targeted computer-generated reminders on compliance with HIV care guidelines in a resource-limited setting.

METHODS

We conducted this randomized, controlled trial in an HIV referral clinic in Kenya caring for HIV-infected and HIV-exposed children (<14 years of age). For children randomly assigned to the intervention group, printed patient summaries containing computer-generated patient-specific reminders for overdue care recommendations were provided to the clinician at the time of the child's clinic visit. For children in the control group, clinicians received the summaries, but no computer-generated reminders. We compared differences between the intervention and control groups in completion of overdue tasks, including HIV testing, laboratory monitoring, initiating antiretroviral therapy, and making referrals.

RESULTS

During the 5-month study period, 1611 patients (49% female, 70% HIV-infected) were eligible to receive at least 1 computer-generated reminder (ie, had an overdue clinical task). We observed a fourfold increase in the completion of overdue clinical tasks when reminders were availed to providers over the course of the study (68% intervention vs 18% control, P < .001). Orders also occurred earlier for the intervention group (77 days, SD 2.4 days) compared with the control group (104 days, SD 1.2 days) (P < .001). Response rates to reminders varied significantly by type of reminder and between clinicians.

CONCLUSIONS

Clinician-targeted, computer-generated clinical reminders are associated with a significant increase in completion of overdue clinical tasks for HIV-infected and exposed children in a resource-limited setting.

Home-based HIV counselling and testing in western Kenya

BACKGROUND

The World Health Organisation (WHO) estimates that only 12% of men and 10% of women in sub-Saharan Africa have been tested for HIV and know their test results. Home-based counselling and testing (HBCT) offers a novel approach to complement facility-based provider initiated testing and counselling (PITC) and voluntary counselling and testing (VCT) and could greatly increase HIV prevention opportunities. However, there is almost no evidence that large-scale, door-to-door testing is even feasible in settings with both limited resources and significant stigma around HIV and AIDS.

OBJECTIVE

To describe our experience with the feasibility and acceptance of home-based HIV counselling and testing (HBCT) in two large, rural, administrative divisions of western Kenya.

DESIGN

The USAID-AMPATH Partnership conducted population-based, house-to-house HIV counselling and testing in western Kenya between June 2007 and June 2009. All individuals aged > or = 13 years and all eligible children were offered HBCT. Children were eligible if they were above 13 years of age, and their mother was either HIV-positive or had unknown HIV serostatus, or if their mother was deceased or whose vital status was unknown.

SETTING

Kosirai and Turbo Divisions, Rift Valley Province, Kenya.

RESULTS

There were 47,066 households approached in 294 villages: 97% of households allowed entry. Of the 138,026 individuals captured, 101,167 individuals were eligible for testing: 89% of adults and 58% of children consented to HIV testing. The prevalence of HIVin these communities was 3.0%: 2.7% in adults and 3.7% among children. Prevalence was highest in the 36-45 year age group and was almost always higher among women and girls. All persons testing HIV-positive were referred to Academic Model Providing Access to Healthcare (AMPATH) for further assessment and care; all consenting persons were counselled on HIV risk-lowering behaviours.

CONCLUSION

Home-based HIV counselling and testing was feasible among this rural population in western Kenya, with a majority of the population accepting to get tested. These data suggest that scaling-up of HBCT is possible and may enable large numbers of individuals to know their HIV serostatus in sub-Saharan Africa. More research is needed to describe the cost-effectiveness and clinical impact of this approach.

Evaluation of an Android-based mHealth system for population surveillance in developing countries

OBJECTIVE

In parts of the developing world traditionally modeled healthcare systems do not adequately meet the needs of the populace. This can be due to imbalances in both supply and demand--there may be a lack of sufficient healthcare and the population most at need may be unable or unwilling to take advantage of it. Home-based care has emerged as a possible mechanism to bring healthcare to the populace in a cost-effective, useful manner. This study describes the development, implementation, and evaluation of a mobile device-based system to support such services.

MATERIALS AND METHODS

Mobile phones were utilized and a structured survey was implemented to be administered by community health workers using Open Data Kit. This system was used to support screening efforts for a population of two million persons in western Kenya.

RESULTS

Users of the system felt it was easy to use and facilitated their work. The system was also more cost effective than pen and paper alternatives.

DISCUSSION

This implementation is one of the largest applications of a system utilizing handheld devices for performing clinical care during home visits in a resource-constrained environment. Because the data were immediately available electronically, initial reports could be performed and important trends in data could thus be detected. This allowed adjustments to the programme to be made sooner than might have otherwise been possible.

CONCLUSION

A viable, cost-effective solution at scale has been developed and implemented for collecting electronic data during household visits in a resource-constrained setting.

Using computerized provider order entry to enforce documentation of tests with pending results at hospital discharge

BACKGROUND

Small numbers of tests with pending results are documented in hospital discharge summaries leading to breakdown in communication and medical errors due to inadequate followup.

OBJECTIVE

Evaluate effect of using a computerized provider order entry (CPOE) system to enforce documentation of tests with pending results into hospital discharge summaries.

METHODS

We assessed the percent of all tests with pending results and those with actionable results that were documented before (n = 182 discharges) and after (n = 203 discharges) implementing the CPOE-enforcement tool. We also surveyed providers (n = 52) about the enforcement functionality.

RESULTS

Documentation of all tests with pending results improved from 12% (87/701 tests) before to 22% (178/812 tests) (p = 0.02) after implementation. Documentation of tests with eventual actionable results increased from 0% (0/24) to 50% (14/28)(p<0.001). Survey respondents felt the intervention improved quality of summaries, provider communication, and was not time-consuming.

CONCLUSIONS

A CPOE tool enforcing documentation of tests with pending results into discharge summaries significantly increased documentation rates, especially of actionable tests. However, gaps in documentation still exist.

Data integrity module for data quality assurance within an e-health system in sub-Saharan Africa

OBJECTIVE

Ensuring good data quality within telemedicine and e-health systems in developing countries is resource intensive. We set out to evaluate an approach where in-built functionality within an electronic record system could identify data quality and integrity problems with little human input.

MATERIALS AND METHODS

We developed a robust data integrity module to identify, enumerate, and facilitate correction of errors within an e-health system that is in wide use in sub-Saharan Africa.

RESULTS

The data integrity module was successfully implemented within an electronic medical record system in Western Kenya. Queries were set to fail if one of more records did not meet defined criteria for data integrity. Only one of 14 data integrity checks implemented uncovered no errors. The other queries had errors or questionable results ranging from 51 records to 30,301 records. However, as a proportion of all patients and all observation, the identified records with likely data integrity problems only constituted a small percentage of all records (mean 0.96%, range 0-4.1%). Twelve of the 14 queries (86%) were executed in<15 s, with the longest query lasting 2 min and 18 s.

CONCLUSION

A tool that allows for automatic data integrity and quality checks was successfully implemented within an e-health system in sub-Saharan Africa. The tool potentially reduces the burden of maintaining data quality by limiting the scale of manual reviews needed to identify electronic records with errors.

Ethics of implementing Electronic Health Records in developing countries: points to consider

Electronic Health Record systems (EHRs) are increasingly being used in many developing countries, several of which have moved beyond isolated pilot projects to active large-scale implementation as part of their national health strategies. Despite growing enthusiasm for adopting EHRs in resource poor settings, almost no attention has been paid to the ethical issues that might arise. In this article we argue that these ethical issues should be addressed now if EHRs are to be appropriately implemented in these settings. We take a systematic approach guided by a widely accepted ethical framework currently in use for developing countries to first describe the ethical issues, and then propose a set of 'Points to Consider' to guide further thinking and decision-making.

Sensitivity analysis for causal inference using inverse probability weighting

Evaluation of impact of potential uncontrolled confounding is an important component for causal inference based on observational studies. In this article, we introduce a general framework of sensitivity analysis that is based on inverse probability weighting. We propose a general methodology that allows both non-parametric and parametric analyses, which are driven by two parameters that govern the magnitude of the variation of the multiplicative errors of the propensity score and their correlations with the potential outcomes. We also introduce a specific parametric model that offers a mechanistic view on how the uncontrolled confounding may bias the inference through these parameters. Our method can be readily applied to both binary and continuous outcomes and depends on the covariates only through the propensity score that can be estimated by any parametric or non-parametric method. We illustrate our method with two medical data sets.

Evaluation of computer-generated reminders to improve CD4 laboratory monitoring in sub-Saharan Africa: a prospective comparative study

OBJECTIVE

Little evidence exists on effective interventions to integrate HIV-care guidelines into practices within developing countries. This study tested the hypothesis that clinical summaries with computer-generated reminders could improve clinicians' compliance with CD4 testing guidelines in the resource-limited setting of sub-Saharan Africa.

DESIGN

A prospective comparative study of two randomly selected outpatient adult HIV clinics in western Kenya. Printed summaries with reminders for overdue CD4 tests were made available to clinicians in the intervention clinic but not in the control clinic.

MEASUREMENTS

Changes in order rates for overdue CD4 tests were compared between and within the two clinics.

RESULTS

The computerized reminder system identified 717 encounters (21%) with overdue CD4 tests. Analysis by study assignment (regardless of summaries being printed or not) revealed that with computer-generated reminders, CD4 order rates were significantly higher in the intervention clinic compared to the control clinic (53% vs 38%, OR = 1.80, CI 1.34 to 2.42, p < 0.0001). When comparison was restricted to encounters where summaries with reminders were printed, order rates in intervention clinic were even higher (63%). The intervention clinic increased CD4 ordering from 42% before reminders to 63% with reminders (50% increase, OR = 2.32, CI 1.67 to 3.22, p < 0.0001), compared to control clinic with only 8% increase from prestudy baseline (CI 0.83 to 1.46, p = 0.51). Limitations Evaluation was conducted at two clinics in a single institution.

CONCLUSIONS

Clinical summaries with computer-generated reminders significantly improved clinician compliance with CD4 testing guidelines in the resource-limited setting of sub-Saharan Africa. This technology can have broad applicability to improve quality of HIV care in these settings.