Health Affairs: E-Health in the Developing World

This issue of Health Affairs focuses on aspects of e-health in the developing and developed world. Below are some titles and authors included in the issue and some excerpted or summarised selections from the parts of the issue that are available online. The issue’s cluster of e-health papers grew out of a Rockefeller Foundation conference "Making the eHealth Connection: Global Partners, Local Solutions", Bellagio, Italy, in 2008.

From The Editor-in-Chief:

• E-Health’s Promise for the Developing World - Susan Dentzer introduces current trends in e-health with the example of Rwanda, where health workers in remote clinics are accessing a national health registry database tracking information on patients and medication histories to inform researchers about, for example, ways to improve medication adherence, "tapping modern information and communications technology to transform health and health care... In part, the papers constitute a broad review of the multiple e-health applications already in use in Asia, sub-Saharan Africa, and Latin America. They also discuss issues to be addressed so that e-health’s potential can be achieved. These include establishing global 'interoperability' standards for information exchange, and building a health informatics workforce with competencies tailored to various nations or regions. Also critical will be evaluating future e-health programs to make certain that what seems to be their potential is more than technological fantasy.... If the transforming of technology is one theme of this issue, another is transformation and change. Despite the disparities among nations, we clearly face common challenges in expanding access to health and health care among disenfranchised peoples everywhere."

People and Places: Interview with Richard Gakuba, the national e-health coordinator for Rwanda’s health ministry.

Policies and Potential:

• An Agenda for Action on Global E-Health - Ticia Gerber, Veronica Olazabal, Karl Brown, and Ariel Pablos-Mendez report from the Rockefeller Foundation’s conference that: "conference participants proposed global partnerships, health technology solutions based on local needs, cross-border interoperability, leveraging current open-source networks, and shared informatics systems; they achieved progress on a shared, cross-border understanding of e-health solutions and policy. Early steps toward furthering these goals include creation of a new organization, the mHealth Alliance, to coordinate efforts, but collaborative investments are needed to usher in the promise of e-health."
  
• Global E-Health Policy: A Work in Progress - Maurice Mars and Richard E. Scott write on e-health’s ability to transcend socio-political boundaries, holding the potential to create a borderless world for health systems and health care delivery. But they find that the policy needed to guide e-health development is limited and just now emerging in developed countries. Further, they state that what’s needed to foster e-health growth in the developing world is thoughtful policy to facilitate patient mobility and data exchange, across both international borders and regional boundaries within countries.
  
• E-Health Technologies Show Promise in Developing Countries - Joaquin A. Blaya, Hamish S.F. Fraser, and Brian Holt present a systematic review of evaluations of e-health implementations in developing countries which found promise in systems that improve communication between institutions, assist in ordering and managing medications, and help monitor and detect patients who might abandon care. Evaluations of personal digital assistants and mobile devices have demonstrated that such devices can be very effective in improving data collection time and quality. They conclude that donors and funders should require and sponsor outside evaluations to ensure that future e-health investments are well-focused.

Cell Phones and M-Health:

• 'Mobile' Health Needs and Opportunities in Developing Countries - James G. Kahn, Joshua S. Yang, and James S. Kahn examine various m-health applications used to respond to both chronic and communicable types of disease burdens and define the risks and benefits of each. They find positive examples but little solid evaluation of clinical or economic performance, which highlights the need for such evaluation.
• Enhancing ‘M-Health’ with South-to-South Collaborations - Walter H. Curioso and Patricia N. Mechael report that most hardware development for cell phone solutions comes from more developed countries of the global North. However, North-South collaboration means that "[f]rom both these countries as well as developing countries in the global 'South' are coming applications that enable health workers to collect and organize data, access diagnostic and treatment support, and promote healthy behavior. Most are still in pilots or demonstration phases, but their use is accelerating."

Investment and Innovation:

• A Toolkit for E-Health Partnerships in Low-Income Nations - William M. Tierney, Andrew S. Kanter, Hamish S.F. Fraser, and Christopher Bailey state that "[l]ow-income countries often lack the information technology that is taking root in developed countries to manage health data and work toward evidence-based practice and culture. Partnerships between academic and government institutions in high- and low-income countries can help establish health informatics programs. These programs, in turn, can capture and manage data that are useful to all parties. Several partnerships among academic institutions and public and private organizations, in areas such as sub-Saharan Africa, Haiti, and Peru, are leading the way."
• Building a Health Informatics Workforce in Developing Countries - William Hersh, Alvaro Margolis, Fernán Quirós, and Paula Otero report that "there is an inadequate supply of skilled individuals who have the technical skills to use this technology to improve health care. Some studies project workforce needs of tens of thousands in English-speaking developed countries, but it is not known what size workforce will be required in the developing world. It is important to identify and develop the skills, training, and competencies - consistent with local cultures, languages, and health systems - that will be needed to realize the full benefits of these technologies." They present a framework for answering these questions and for developing estimates of the size and scope of the workforce that may be needed.
  
• Accelerating Innovation in Information and Communication Technology for Health - Kevin W. Crean explains that "it is very difficult to find investment funding needed to create business models to expand and develop the prototype technologies. A comprehensive, long-term investment strategy for e-health and m-health is needed. The field of social entrepreneurship offers an integrated approach to develop needed investment models, so that innovations can reach more patients, more effectively. Specialized financing techniques and sustained support from investors can spur the expansion of mature technologies to larger markets, accelerating global health impacts."
• Connecting Information to Improve Health - W. Ed Hammond, Christopher Bailey, Philippe Boucher, Mark Spohr, and Patrick Whitaker found that "health data most likely come from many different and unconnected systems - but must be organized into a composite whole. We use the word interoperability to capture what is required to accomplish this goal. We discuss five priority areas for achieving interoperability in healthcare applications (patient identifier, semantic interoperability, data interchange standards, core data sets, and data quality), and we contrast differences in developing and developed countries. Important next steps for health policy makers are to define a vision, develop a strategy, identify leadership, assign responsibilities, and harness resources."

DataWatch:

• Funding Growth Drives Community Health Center Services - Anthony T. Lo Sasso and Gayle R. ByckUs connect United States (US) investments made in federally qualified health centres, 1996-2006, to an increase in services available to patients, including mental health and substance abuse treatment and counselling and staffing, noting that an additional US$500,000 in federal grants translates into 540 more uninsured US patients treated.

Prevention:

• Workplace Wellness Programs Can Generate Savings - Katherine Baicker, David Cutler, and Zirui Song report their critical meta-analysis of the literature on costs and savings associated with US wellness programmes. "[W]e found that medical costs fall by about US$3.27 for every dollar spent on wellness programs and that absenteeism costs fall by about US$2.73 for every dollar spent." 

Long-Term Care:

• Person-Centered Care for Nursing Home Residents: The Culture-Change Movement - Mary Jane Koren reports that "[t]he ‘culture change’ movement represents a fundamental shift in thinking about nursing homes. Facilities are viewed not as health care institutions, but as person-centered homes offering long-term care services. Culture-change principles and practices have been shaped by shared concerns among consumers, policy makers, and providers regarding the value and quality of care offered in traditional nursing homes. They have shown promise in improving quality of life as well as quality of care, while alleviating such problems as high staff turnover. Policy makers can encourage culture change and capitalize on its transformational power through regulation, reimbursement, public reporting, and other mechanisms."

The issue is accompanied by a series of online video presentations and discussions available here.