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Developing new Health IT in the Developing World

By Leonard Davolio | 17 Mar, 2015

Hello All,

I recently published an article on the various ways that the developing world is better than the US when it comes to IT innovation. It garnered some views published at InformationWeek but was hoping it would spark ideas, conversation - particularly of the global variety. I'm new to GHD Online and figured this might be a good way to learn more about the platform and its potential. Thanks and I look forward to hearing from you!

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A/Prof. Terry HANNAN Moderator Replied at 6:25 PM, 17 Mar 2015

Leonard, I have read your interesting postings and the following stood out as an interesting point to focus upon.
"Aligned incentives: Having a problem to solve is certainly a prerequisite for innovation. And there are no shortages of challenges in delivering healthcare both locally and abroad. However, as we've seen in the US, without economic incentives, the greatest solutions do little more than consume venture capital or take up shelf space in medical libraries. In contrast, the healthcare systems of many developing nations are economically incentivized to invest in improving care."
I may have the wrong impression but the two citations you posted raise in my mind concerns over what are the problems we are trying to solve? Is the drive for the innovations you allude to, economic or improved health information management? If not the latter then we are likely to see failures in associated with e-technologies in Low and Middle Income Nations. An indication that the solutions are not solely technology based is the recent WHO report that indicates that >95% of the adult population in the world will have a mobile phone (m-Health) by the end of 2015 yet there a only a FEW areas where these technologies have been shown to have significant impact on care delivery.
As the WHO also documents, "‘there is no health without management, and there is no management without information’." [Leao BF. Terms of Reference for Designing the Requirements of the Health Information System of the Maputo Central Hospital and Preparation of the Tender Specifications. Geneva: World Health Organization. 2007.]
Also first hand experiences in the LMIC e.g. AMPATH confirm that a major component for HIT success is the need to "physically and metaphorically sit in the dirt with the end users" [W. Tierney, Regenstrief]. These experiences also allowed the establishment of criteria for the successful implementation of e-Health solutions (in all economies). The LAST point being the most critical.
LOW COST: preferably free/open source
CLINICALLY USEFUL: feedback to providers and caregivers is critical. If the system is NOT CLINICALLY USEFUL it will not be used
Mamlin BW, Biondich PG, Wolfe BA, Fraser H, Jazayeri D, Allen C, et al. Cooking up an open source EMR for developing countries: OpenMRS - a recipe for successful collaboration. AMIA Annu Symp Proc. 2006:529-33. Epub 2007/01/24.

Richard Pankomera Replied at 7:32 PM, 17 Mar 2015

"Physically and metaphorically sit in the dirt with the end users", sorry for me , I had to read this clause twice before I made sense out of it. I have liked this peace. There is nothing more exciting than meeting something you have not met before !! I usually like your contribution.

A/Prof. Terry HANNAN Moderator Replied at 7:34 PM, 17 Mar 2015

I also forgot to post this-rushing to a conference.

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Leonard Davolio Replied at 7:50 PM, 17 Mar 2015

Hello Prof. Hannan and thanks very much for starting the discussion with a very useful set of points. Hard to argue with any of your insights:
-Technology alone doesn't cure a thing
-Understanding user requirements is a prerequisite to the design of useful systems
-If the system is not clinically useful it will not be used

I am saddened but not surprised to learn that the WHO finds that the pace of impactful mHealth solutions lags behind the explosive rate of mobile phone adoption. But I am convinced that the future for low-cost mobile supported healthcare delivery is promising.

Now to the more provocative question you pose: what is it we're striving for here - innovations for economic gains or improved health information management?

We strive for improved healthcare. Improved information management is a means to an end. Or at least that's my position as a member of the BetterBirth team at Ariadne Labs working in Uttar Pradesh, India. But the point of the piece is that (whether we care to acknowledge it or not) innovation follows the money. Misaligned incentives in the US have created an environment hostile to health IT innovation. So why not seek new partnerships and ideas in places that are more amenable? In an appropriately incentivized market, failed attempts at healthcare-driven IT will be punished accordingly. And if writing of promising new markets to an audience of American technologists drives resources to places in need, I'm ok with that:)

I would love to learn more of these few success stories. Who's finding new ways to delivery health? Even more importantly, who has learned lessons the hard way?

I personally was impressed by the "Swasthya Slate" (link below) and it's creator. Are there others to be aware of?

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Luis Azpurua Replied at 9:27 AM, 21 Mar 2015

Hi Leonardo,

Very interesting the Swasthya Slate device.

Right now we are figuring out in Venezuela how to provide healthcare to the mostly needed people investing 6 - 12 dollars per capita a month. On our quest we have understood a couple of things: that we have to focus on primary care and informatics technology (IT) is a must.

This device is a promise to our project. It could be used by trained people from the community, send the information to a medical hub where they process it and could give a response throughout a community doctor. In this way we could use this device as a mean to lower the heathcare costs, give coverage to that important percentage of the population (Accessibility) and still providing high quality health care.

Professor Hannan,

I have learned with your posts, and I am willing to learn a lot more!

Here in Venezuela we have clusters of health IT, mainly EHR on private practices / hospitals, but we lack of an IT system that integrates all the information.

I have dreamed to devise a Health IT system that begins with the birth certificate and ends with the death cetificate. In this system wherever the patient look for health services (public or private settings) the data could be added to his/her record. On this way everyone on the healthcare system with the proper authorization could have access to it. Among others this system should be designed to get epidemiological data (Epidemiological intelligence?) and thus be able to give the needed information to create public healthcare policies.

I know that this envisioned system will have many obstacles to overcome. But I keep figuring out how to create it.

Ronald Munjoma Replied at 10:00 AM, 21 Mar 2015

Hi Luis,

​Please have a look at http://health.gnu.org/​

​Gnu Health Supports these vital records:

​The Jamaican Ministry of Health implementation of GNU Health shares
patient records across all the hospitals and clinics owned by the
government. ​

​Best and Regards
Ronald Munjoma

Leonard Davolio Replied at 3:14 PM, 22 Mar 2015

Luis and Ronald,

Thanks very much for sharing. I'm not expert in what's happening in the developing world regarding EMR tech but I'm very excited about what current IT architectures are making possible. The proliferation of mobile devices and more reliable networks makes synchronous and nearly synchronous communication possible and more simple standards for EMR data descriptions are showing early signs that they might to take hold (at least in the US - what happens with govt incentivized "Meaningful Use 3" will be pivotal). This means that the "brains" of an EMR system can be centrally hosted and light weight, "dumb" terminals (e.g., mobile phones, tablets, cheap laptops) can collect and receive data far more easily. No more traveling to install software on computers, supporting computers, hoping software versions are consistent, etc. $100 devices can be online in minutes, updated automatically, and easily swapped out. Meanwhile, more complex software can reside in a central location anywhere in the world, offering opportunities of scale.

For example, in our BetterBirth program in Uttar Pradesh India we have a growing army of public health officials capturing neonatal and maternal outcomes as well as birth attendant behaviors. The phones host software that is automatically updated / maintained from a central location. The data is communicated to an Amazon Web Services HIPAA-compliant instance (patient privacy protected). In Boston we host more complex reporting / analytics applications that turn the raw data into actionable insights that are shared with our field teams, Chief Medical Officers, govt officials, and birth attendants (custom views per user type). They can see how they did yesterday, last week, where do they need additional help, how did their patients fare, etc. It's not an EMR system but it has been very encouraging to see how quickly we've moved past so many of the limitations of the client-served architecture to something more lightweight, flexible, and cost-efficient. I believe it will be this model, with centralized, cloud-based intelligence and cheap, light-weight devices that will pave the way for the type of system you're looking for Luis.

I'm sure there are already examples / progress in this space. Please share!

Leonard Davolio Replied at 3:15 PM, 22 Mar 2015

correction, "a growing army of public health officials" should read "public health workers". Pardon the mistake

A/Prof. Terry HANNAN Moderator Replied at 4:33 PM, 22 Mar 2015

Leonard, you are right on the ball. I am not sure if you have seen the following.
1. MDRTB Pakistan: http://www.youtube.com/watch?v=1N8236ReWnM
2. IRDResearch Data visualization using Google Earth: http://www.youtube.com/watch?v=v-3lqG3hSYM
3. MiDoctor: www.ehs.cl / http://www.youtube.com/watch?v=Kxs6SESydA4

Leonard Davolio Replied at 9:44 PM, 22 Mar 2015

Excellent! Thanks for sharing Terry

Luis Azpurua Replied at 11:30 AM, 23 Mar 2015


Thanks a lot for your comment. I'll take a look of the Jamaican Health IT

Leonard and Prof. Hannan, thank you for your comments. I agree with you that the mobile technology is the most available to everyone and maybe the cheaper one. On this we have to aim our efforts. The next step is using the mobile phone as diagnostic tool.

It may sound weird what I am going to say, Do you remember Dr. Spock of the Star Trek saga? He had a little device in which he could make a diagnosis without invading the patient (as I remember!). Are we getting closer to this kind of technology nowadays?


David Aylward Replied at 4:29 PM, 23 Mar 2015

Luis: the XPrize Foundation and Qualcomm have initiated the Tricorder
Challenge to replicate Mr. Spock's magic device -- for real. Lots more
information at this link: http://tricorder.xprize.org/

Luis Azpurua Replied at 5:12 PM, 23 Mar 2015

David: thanks a lot for the information!

Well, I'm smiling because when I wrote the comment I thought I was pushing too much the boundary of the imagination...

Creativity and innovation have no limits

Derek Ritz Replied at 12:44 AM, 24 Mar 2015

OK... I'm sorry to have to make such picky and small contribution to the discussion... but it was Bones (Dr. McCoy), not Spock. Once a Trekker... :-)

David Aylward Replied at 8:22 AM, 24 Mar 2015

Ritz: once a techie . . .

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