Global Heath Informatics

Definition

Global Health Informatics (GHI) is the informatics discipline focused on empowering people to use appropriate technology to provide information-based solutions with a global perspective that support health care for all.

The mission of GHI is to share informatics knowledge, skills, and research, and to foster local innovations to promote the highest standards of health for all with an emphasis on low-income, low-resource countries, and the medically underserved.

The scope of GHI especially includes low- and middle-income countries (LMICs), international health, and indigenous and refugee population. A central consideration is the global north-south divide and the sociotechnical determinants of and impacts on the digital health maturity of LMIC.

History

The foundation of global health can be traced back to the 1978 World Health Organization (WHO) Declaration of Alma-Ata, later followed by the 2000 United Nations Millennium Development Goals (MDG), calling for action by governments and the world community to promote health of all the people of the world and setting concrete goals for improving health outcomes. Since then, many US-based non-profit organizations played a major role in supporting initiatives to reach the MDG health-related goals, such as the Bill and Melinda Gates Foundation and Rockefeller Foundation. The 2003 United States President’s Emergency Plan for AIDS Relief (PEPFAR) committed funding to support capacity building and strategic information combating HIV/AIDS, tuberculosis and malaria in 15 focus countries, later expanded to 49 regional programs (PEPFAR II, 2008). The use of electronic health information systems was a critical component of the PEPFAR implementation, which were developed to help report core indicators required for funding. These indicators were also used for policy development, program planning and implementation, and identification of best practices. As health information infrastructure matured, patient-level data collection systems were implemented to be used for both patient care in addition to health surveillance and resource planning. The efforts have since shifted to building partnerships with countries to create sustainable health information systems. Local political and environmental factors affect the level of success in this endeavor.

Another critical milestone was the award of International Training in Medical Informatics (ITMI) grants by the NIH Fogarty International Center and the National Library of Medicine starting in 1999. Recipients of the award, including the AMPATH project in Kenya, among other, started a number of critical technology including early EHR projects, and in 2004 combined their work and that of Partners In Health to create the OpenMRS open-source EHR system now widely used in LMICs. The Rockefeller Foundation and WHO sponsored Bellagio Meetings in 2008 and 2011 brought together many early pioneers in GHI and laid key foundations for the field. Ongoing work by Partners In health, the University of Washington, the University of Pennsylvania, Columbia University, and other universities contributed to ongoing development of GHI.

Principles

General principles

While use-cases and challenges might be quite different, the core informatics principles required were common, including data models, vocabularies, scalable architectures, clinical decision support, interoperability, and usability.

In 2016, global consensus on the Principles for Digital Development was developed to serve as a best practice guide. The following principles were included:

• Design with the user
• Understanding the existing ecosystem
• Design for scale
• Build for sustainability
• Be data driven
• Use open standards, open data, open source and open innovation
• Reuse and improve
• Address privacy and security
• Be collaborative

Partnership

Interoperable, sustainable, capacity-building, and locally led initiatives are critical to partnerships. Collaborations must be mutually beneficial and preserve data sovereignty in order to avoid historical pitfalls of pilotitis, unequal partnerships between research investigators, and projects that do not benefit the local community. In many of the most successful projects, innovation has been shared between teams in high- and low- or middle-income countries.

In the article A Toolkit for E-Heath Partnership, the authors identified six key steps for partnerships:

• Dissemination of details of successful partnerships, through regular meetings or other exchanges in which e-health partners share their methods and provide mutual support.
• The funding of new multidisciplinary relationships among academic, public, and private partners.
• Support for mentoring relationships between successful and new partnerships.
• Development of training programs including on-site, off-site, and Web-based learning initiatives—to support the effective use of e-health tools in developing countries.
• Ensuring local commitment. Health informatics initiatives will become sustainable and serve local populations only if those implementing e-health tools have a sense of ownership of these systems and believe that they will ultimately pay for themselves through increased efficiency of health systems. Through training, mentoring, and ongoing support, their international partners must build local capabilities and capacities, not dependencies.

Existing interdisciplinary academic partnerships include AMPATH, Millennium Villages, Partners In Health, RAFT, Global Partnership Program, among others. Additionally, partnership among public and private organizations are encouraged to foster improvements in health information system and health care delivery, such as by Gates Foundation, or Informatics Training for Global Health program of the NIH Fogarty International Center.

Clinical Information System Implementation in Developing Countries

Clinical Information System (CIS) includes electronic healthcare records (EHR), clinical decision support, computerized provider order entry, digital sources of medical evidence and decision-support tools, ancillary information systems, among others. It has been proven to be effective in reducing cost, improving care quality and outcome, and provider efficiency, if implemented correctly. However, CIS implementation is challenging even for developed countries, requiring continuous education, analysis and improvement. LMICs face unique challenges compared with developed countries in CIS implementation process.

In a systematic review analyzing CIS implementation in developing countries, six major requirement categories and success factors were identified. In addition, factors unique to the developing countries under each category were identified, as listed below. Priority should be given to these factors when implementing CIS in developing countries. Of note, “training and Technical Support” having the highest contribution among these factors, which implies that long-term plans for local workforce training considerably improves CIS success rates in developing countries.

• Project management: research; quality control; dual optional system with optional usage; realistic time frame; phase-based implementation; sustainability of CIS
• Financial resources: budgeting methods; sufficient budget for continued operation; dedicated budget for CIS projects
• Government involvement and support: data ownership, privacy and security; government policy; strategic IT planning; investment in alternative infrastructure
• Human resources: managerial IT knowledge; skilled staffs; developing expertise for the system
• Organizational: social factors; clinical staff involvement; stakeholder consensus; appropriate business and IT systems; organizational support; incentivizing health informatics
• Technical requirements: hardware and software compatibility; hardware quality and quantity; electricity; infrastructure support; Internet availability; prompt attendance to system maintenance; in-office or web-based; automated data conversion and analysis; office automation

Open-source EHR system

Open-source EHRs have been wildly used by source limited regions in all continents, especially in Sub-Saharan Africa and South America. The most widely used EHR in LMICs is OpenMRS, developed with the collaboration between Partners In Health, AMPATH and the Regenstrief Institution in 2004 and initially implemented in Kenya followed by Rwanda. Since then it has become the most widely used in resource-limited areas in Africa, India, and South East Asia, due to its cost-efficiency and flexibility to modify and improve. In Brazil and some other parts of the world, OpenEHR is more popular.

Compared with other popular open source EHRs, such as VistA and OpenEMR, the mainstay open-source EHR in the United States, both OpenMRS and OpenEHR have limitations in many core function areas (eg, order entry), interoperability-focused areas (eg, transition of care), or privacy and security-focused areas (eg, end-user device encryption)(7).

Digital health as Intervention

The WHO Classification of Digital Health Interventions categorizes the different ways in which digital and mobile technologies are being used to support needs and address challenges in the health system, and provides a roadmap for governments and policymakers in introducing and scaling up digital health interventions to support population health outcomes.

Challenges and Pitfalls

In Journal of the American Medical Informatics Association's focus issue on GHI, multiple informatics challenges in LMIC environments were identified:

• limited EHR systems used at the point of care
• Databases that have been developed to meet funder rather than clinical needs
• Lack of foundational work that can support interoperability and data sharing
• Inadequate health informatics workforce limited by resources, access to training and mentoring

In the article A Toolkit for E-Heath Partnership, the authors identified four challenges in GHI partnership:

• Cultural differences and geographic distances.
• Miscommunication and misunderstanding.
• Maintaining funding and momentum for initiatives.
• Lack of consistent, basic services such as electricity and Internet connectivity.

Additional challenges listed in our resources include:

• Lack of governance and policy
• Disjoint public and private sector systems, creating non-interoperability
• Multiple vertical programs does not integrate
• Additional socio-cultural issues, such as resistance to change
• Local ownership of solutions

References

Submitted by Mengyu Zhou