Description of the condition
The World Bank/World Health Organization (WHO)/US Agency for International Development (USAID) Roadmap for Health Measurement and Accountability Post-2015 (MA4Health) report underlined that “Public health and clinical care cannot be delivered safely, with high quality, and in a cost-effective manner, without seamless, sustainable, and secure data and information exchanges at all levels of the health system” (Haazen 2015). The report further specifies that countries should have comprehensive databases and electronic tracking systems that support the delivery of quality health services and allow providers to follow up with clients over a period of time, whether within the facility or in the community. An effective healthcare system should have the capacity to store, share, and use health data, so that providers can use information to improve not just clinical care, but also treatment co-ordination and disease management. Better data on health status are critical for addressing various coverage and quality of care bottlenecks with the goal of achieving universal healthcare coverage (Froen 2016).
Such functional health information systems, when available, can provide additional opportunities for improving the quality and safety of preventative and clinical healthcare services. Too often, providers lack information on which treatments work best for which clients - whether this void is due to limited training, insufficient time to keep abreast of current evidence, or the sheer complexity of the disease. In primary health care, despite the availability of knowledge and of specific diagnostic, treatment, and management protocols, a discrepancy exists between knowledge and its application. This ‘know-do’ gap in the quality of health care has been widely cited as a key barrier to optimal healthcare outcomes (Blank 2013; Mohanan 2015).
For clients receiving primary healthcare services, interactions with providers during healthcare appointments remain key opportunities to receive evidence-based clinical information customised to the individual's specific health needs. Limited interactions with the healthcare system between clinical appointments often result in poor engagement in care, for example, poor adherence to a recommended clinical care plan or medication regimen. In low-resource settings, a shortage of trained healthcare professionals combined with a low provider-to-patient ratio often translates into additional barriers for clients who wish to receive counselling or information that would help them manage their health or learn about available preventative health measures.
Description of the intervention
Several obstacles to maintaining robust client health records, improving the clinical practices of providers, and engaging with clients may be addressed by digital interventions using mobile devices. Digital tracking is characterised by longitudinal follow-up of a client's health status conducted by digitally entering and accessing data on healthcare services utilised by the client. Digital tracking of a client's health information and service utilisation may involve digitisation of traditionally paper health records (such as medical registers and logbooks of services with a longitudinal care plan for antenatal and postnatal care, immunisation or diabetes). By using such digitised records, providers can uniquely identify each client and can digitally follow client interactions with the healthcare system/services for health concerns that require continuity of care (e.g. pregnancy, diabetes).
Systems designed to track and manage preventative and clinical care will allow providers to capture, store, access, and share client information during the care encounter. Tracking of health status enables individual care planning, close management, and potentially prevention of episodes of acute illness and declining health status (WHO/ITU 2012). Additionally, tracking may facilitate aggregation, analysis, and synthesis of client data from multiple sources to enable better decisions for client care and more accurate study of disease and service utilisation trends.
In several high-income countries (HICs), sophisticated computerised health records have been widely implemented over the past decade. In low- and middle-income countries (LMICs), where computerised infrastructure may be limited, mobile devices are widely used instead of stationary computers to leapfrog the lack of infrastructure while digitising client health records.
Such digital client health records may be integrated with other tools that provide information to healthcare providers and to clients through their mobile devices. For example, mobile clinical decision support systems (CDSSs) may couple clinical practice guidelines with an accurate base of client information from the digital health record to identify drug interactions, client risks, and appropriate management of disease. A CDSS is “any electronic system designed to aid directly in clinical decision making, in which characteristics of individual clients are used to generate client-specific assessments or recommendations that are presented to clinicians for considerations” (Kawamoto 2005). Mobile CDSSs may vary in range of functionality and applications to improve diagnosis, while facilitating evidence-based screening, counselling, and treatment, and improving workflow efficiencies.
On the client side, digital health records may be integrated with systems designed to improve client adherence to the clinical care plan via targeted communication with clients on their mobile devices. Targeted client communication in this context is defined as transmission of targeted health content to a specified population or to individuals within a predefined health or demographic group. This transmitted information can fall along a continuum of tailored to untailored communication, to include transmission of individualised notifications according to a specific individual clinical care plan, as well as transmission of predetermined content developed for the identified population group (Hawkins 2008). Examples of targeted client communication (TCC) may include appointment reminders, medication reminders, notification of test results, or information on specific health conditions that pertains to the client. To define appropriate populations for TCC, providers need to identify and subscribe eligible individuals into a system that allows transmission of health information. Additionally, the health system must determine the timing and content of transmitted information rather than have clients seeking information on-demand.
How the intervention might work
Longitudinal tracking of client health information varies widely depending on the availability of health infrastructure. In HICs, providers may track client health information using sophisticated electronic medical records. It is expected that such records will conform to nationally recognised interoperability standards, can draw from multiple sources, support a range of disease groups and comorbidities, and can be shared and controlled by healthcare providers and clients (Kahn 2009). These records may be integrated with CDSSs relevant to a specialty or to a high-priority hospital condition (Moja 2014) and may offer additional features that support education and automated follow-up with clients according to their specific health condition.
In most LMICs, such systems tend to vary widely according to available infrastructure and human resources, as well as disease groups. For example, in peri-urban and urban centres that include an extant computerised infrastructure, digital health records customised to the workflows of individual clinics and hospitals may be available. In most primary healthcare settings, the transition from paper records to digital records is still in its infancy. Interoperability standards are not well defined or used in practice, precluding establishing and sharing of digital health records. Longitudinal digital records used to support reproductive, maternal, newborn, and child health, while following care provided to women and infants from prenatal to postpartum stages, are often referred to as electronic registries, or eRegistries (Froen 2016). Like electronic medical records, eRegistries provide an organised system for collecting, managing, and analysing data by using reproductive, maternal, newborn, and child health data to improve women's and children’s health, and serve as an entry point for accessing a range of preventative and curative services and promoting health.
Digital health records may drive multiple mobile applications that can draw on stored client data to guide a provider through next steps (e.g. CDSSs) or to offer additional support to the client in the form of information and reminders (e.g. as TCC). Providers may load electronic databases onto a handheld mobile device to manage diaries, input new client data that later can be synchronised with an external source (Divall 2013), access summary dashboards, and retrieve information and decision support aids based on client-specific information. Broadly, CDSSs may serve the following functions.
Guide the healthcare provider through process algorithms using 'if..then' rules based on evidence-based clinical protocols.
Provide the healthcare provider with a checklist based on clinical evidence-based protocols.
Present step-by-step guidance for screening clients by health status or risk status, possibly using models based on machine learning whereby mathematical functions might be used to classify clients into risk groups.
Providers may use the data stored in digital health records to generate TCC delivered to the client’s mobile device to reach clients near-instantaneously with information that is specifically tailored to their needs. A variety of communication modalities such as text messages, phone calls, interactive voice response systems, unstructured supplementary service data (USSD) messages, multimedia messages, pictures, and in-app alerts might be used in communicating with clients. Such targeted communication with clients may serve several functions.
Targeted health event alerts to clients may alert clients about diagnostics results or availability of results. Efficient delivery of diagnostic results may expedite follow-up, appropriate treatment, and ongoing engagement with care.
Targeted health content based on care plan or demographic health status may be used to improve clients’ knowledge about their health condition, and may positively influence their behaviour and healthcare practices.
Targeted alerts and reminders may be sent to clients to improve adherence to medication regimens and attendance at clinic appointments.
Interventions that integrate digital health records with CDSSs or TCCs are multi-faceted and may vary widely. For example, the mTika immunisation registry system supports vaccinators in registering and tracking children for receipt of recommended childhood vaccinations during the first year of life. Caregivers of children receive appointment reminders via short message service (SMS) to their registered phone number one week before and one day before the scheduled vaccination appointment. In addition to tracking and sending targeted messages to caregivers, mTika offers CDSS components such as vaccination schedules calculated on the basis of the child's date of birth. Another example is the Safer Deliveries programme in Zanzibar (Uddin 2016). This programme helps community health workers (CHWs) register pregnant women via mobile phones. CHWs then visit these women in their homes and offer antenatal care via mobile-based CDSSs throughout pregnancy while preparing women to deliver at a health facility (Dtree International 2017).
Why it is important to do this review
Digital, mobile, and wireless technologies provide an innovative and accessible platform for accelerating health services and improving quality of care. Health records available on mobile devices can facilitate delivery of critical care outside formal healthcare settings within the community, as well as in areas where healthcare facilities may be lacking critical infrastructure. Some evidence shows how such digital health records, when combined with additional tools such as CDSSs, may improve the quality of health services and healthcare outcomes.
A systematic review of 148 randomised trials on effects of CDSS reported significant improvements in healthcare process measures related to preventative services, diagnostic testing, and treatment (Bright 2012). Another systematic review assessed the effectiveness of CDSSs that are integrated with electronic health records. This review of 25 randomised trials concluded that integrated CDSSs did not affect mortality but significantly prevented disease morbidity (Moja 2014). Although this evidence is promising, it does not speak to the effectiveness of interventions provided via mobile devices, especially in low-income settings, where such interventions are in early stages of development.
Several systematic reviews have examined use of TCCs for improving health knowledge, behaviour, and outcomes (Free 2013; Gurol-Urganci 2013; Vodopivec-Jamsek 2012; Whittaker 2016). Much of the available evidence is of low or moderate quality and includes limited studies from low-resource settings that are not conducted in primary healthcare settings. A systematic review of eight randomised trials assessed effects of mobile phone messaging reminders on improving attendance at healthcare appointments. This review concluded that mobile phone text messaging reminders, similar to phone call reminders, were associated with increased attendance at healthcare appointments (Gurol-Urganci 2013). Whittaker 2016 included 12 studies of moderate to high quality and found beneficial impact of mobile phone-based smoking cessation interventions on six-month cessation outcomes. Another systematic review of 75 controlled trials on the effectiveness of mobile technology-based health behaviour change interventions and disease management interventions delivered to healthcare consumers suggested benefits of text messaging for improving antiretroviral treatment adherence and smoking cessation (Free 2013). However, this review found limited evidence from LMICs and noted an overall lack of high-quality trials. None of these reviews focussed on interventions that integrate TCCs with longitudinal digital health records.
The present review assesses evidence on tracking systems accessible via mobile devices integrated with CDSSs and/or TCCs. Given the recent emergence of digital technologies for health, ministries of health, donors, and decision-makers have demanded evidence-based guidance on the value of digital tools in strengthening health system gaps. In response to this global need, the World Health Organization is developing guidelines to inform investments on digital health approaches. This review on digital interventions that use combinations of CDSSs, TCCs, and electronic health records constitutes one of a suite of such reviews. Results of this review will be used to directly inform WHO guidelines on the effectiveness of these strategies in addressing health system shortfalls.