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Panelists of The Expansion of Digital Clinical Resources and GHDonline staff

The Expansion of Digital Clinical Resources

Posted: 13 Jul, 2015   Recommendations: 67   Replies: 125

Digital clinical resources such as UpToDate and DynaMed are on- and off-line tools used to augment medical education and improve patient care.* They offer access to vital clinical information at the point of care and inform providers of the most recent advancements in medicine and best practices. While some of these resources are utilized during the treatment of patients, others are consulted for study and review during leisure time. The recent expansion of these tools in the United States raises questions regarding their global uptake, the barriers restricting their use, and what can be done to overcome these roadblocks.

To discuss these important questions, GHDonline is pleased to host an Expert Panel from July 20 – 24th, with panelists:

     • Leo A. Celi, MD, MS, MPH (July 20-21) – Co-Founder and Executive Director, Sana
     • Anthony Philippakis, MD, PhD – Broad Institute of MIT and Harvard; Venture Partner, Google
     Ventures; Fellow in Cardiovascular Medicine, Brigham and Women’s Hospital
     • Jodi Scarbrough, MBA – Global Business Services Director, Vecna Cares Charitable Trust
     • Luke R. Smart, MD – Weill Cornell Medical College, New York, New York; Weill Bugando School of
     Medicine, Mwanza, Tanzania
     • Traci Wolbrink, MD, MPH – Associate Program Director, OPENPediatrics; Associate in Critical Care
     Medicine, Boston Children’s Hospital
     • Robert Wu, MD, FRCPC, MSc – Assistant Professor in the Department of Medicine, University of
     Toronto

Our expert panelists will share their thoughts on the role of digital clinical resources and address the following questions:

     1. How prevalent are digital clinical resources in resource-limited settings and in what ways are they
     being implemented? What effects have they had on the quality of care provided?

     2. What barriers are prevalent in that limit large-scale uptake of digital clinical resources? What
     incentives are in place for healthcare systems to expand their digital clinical resources?

     3. How can members of the medical community address
     these barriers?

     4. What can be done on a national level through government bodies or corporations to overcome
     these barriers?

     5. Are there any examples or case studies of digital clinical resources that have been implemented on
     a national scale? What lessons can we learn from their success?

To better understand the usage habits and needs of healthcare professionals around the world, we also hope all of our members here will share their experiences with our panelists and the GHDonline community. As someone who actively delivers care, tracks and monitors patients, or supervises other caregivers, you know what point-of-care tools are prevalent in your setting and what barriers there may be to their usage.

We hope that you will all join us by sharing your thoughts on the questions above and joining the conversation with our panelists on this exciting topic. We look forward to a rich discussion, and are grateful for your input.

* Although electronic medical records (EMRs) are important tools in clinical settings, they will not be the focus of this expert panel.

Replies

 

Sudip Bhandari Replied at 10:51 AM, 13 Jul 2015

In preparation for next week's discussion, I want to share a number of resources that might be of interest.

Attached resources:

Gaddo Flego Replied at 11:14 AM, 13 Jul 2015

Thank you for the invitation, I'll join the discussion!
Gaddo.

Fredirick Mashili Replied at 12:03 PM, 13 Jul 2015

Thank you very much,
I will indeed join and contribute accordingly.
Fredirick

*Ag. Director, DICT, MUHAS.*

Fredirick L Mashili, MD, PhD.
Lecturer, Department of Physiology MUHAS and
Bernard Lown Junior visiting scholar (Physical activity & Cardiovascular
health research)

Kee Park Replied at 12:24 PM, 13 Jul 2015

I'll join.
Thanks for the invite!

Madhuri Gandikota Replied at 1:08 PM, 13 Jul 2015

Thanks for the inivite.
I am excited to be a part of this discussion.

Madhuri

Musa Dankyau Replied at 1:43 PM, 13 Jul 2015

Thanks for the invitation. i am looking forward to the discussion

Elizabeth Glaser Replied at 1:55 PM, 13 Jul 2015

Thank you for the invitation. I plan to participate.
Nurses and pharmacists are health care professionals that also access digital clinical resources, therefore their absence from the panel is disappointing.


Elizabeth Glaser, MSc, MA, ACRN,
Doctoral candidate, Social Policy
Heller School for Social Policy and Management
Brandeis University
Director, Global Nursing Caucus

DANIEL ERNEST ELOTU Replied at 2:26 PM, 13 Jul 2015

Thank you for the invite. .....I am expectant. .

Shantanu Nundy Replied at 2:32 PM, 13 Jul 2015

Great topic. I'm a primary care physician and an early member of YP-Chronic, and currently help organize the Human Diagnosis Project (www.humandx.org).

The Human Diagnosis Project (or Human Dx) is a worldwide effort to map any health problem to its possible diagnoses. Human Dx is an open-access, digital clinical resource that enables any health professional around the world to give or receive input on any clinical case.

Unlike tools that are written solely by experts and therefore have limited relevance in many resource-limited settings, Human Dx is organized and led by the global medical community. Our Mission is to empower anyone, anywhere with the world's collective medical insight.

I welcome any member of GHDonline to join the Human Diagnosis Project community and also to help us increase access in resource-limited settings.

-Shantanu Nundy, M.D.

Attached resource:

Jorge Lazareff Replied at 3:47 PM, 13 Jul 2015

Thank you for the invitation. Glaldy will join you and if possible share our experience with students and physicians in Nicaragua

Stephen Martin Replied at 6:08 PM, 13 Jul 2015

Hi All,

Very much appreciate your looking at this topic. I'm the project director
for TandemHealth, a joint partnership of the National Physicians Alliance
and Consumer Reports. We're in beta currently and would appreciate your
looking at our work, offering feedback, and helping us consider
dissemination and sustainability for this tool.

Please see our brief description and link below.

All best,
Steve

*Level playing field. Understandable information. Shared decision-making.
Independent, trusted, and free to users. Conversations between patients and
clinicians. Transparent costs.*

*That’s what everyone wants in healthcare. Why isn’t it happening? To
start, you need the right tool.*

*We’re creating it. *

*TandemHealth is a partnership of Consumer Reports and the National
Physicians Alliance, the same groups that developed Choosing Wisely®. We’re
bringing our track record of independence and consumer advocacy to
professional schools, clinics, homes, pharmacies -- wherever this
information is needed -- and giving a guide to the conversations people
want to have. *

*Get started at www.tandemhealth.org <http://www.tandemhealth.org>.*

Stephen Martin, MD, EdM | Project Director
TandemHealth | National Physicians Alliance
Website <http://tandemhealth.org/> Email <>
<http://lnkd.in/MgfbBr>

Murali Ramachandran Replied at 6:41 PM, 13 Jul 2015

Thanks for the invitation- and informing other resources
Will participate in the Discussion.
Dr.Murali

Bashiru Ismaila Replied at 6:57 PM, 13 Jul 2015

Many thanks

Looking forward to it.

Yudha Saputra Replied at 1:40 AM, 14 Jul 2015

Dear Damir and colleagues,

Thank you very much for the invitation. Approximately four months has past after my graduation of pharmacist education in Indonesia. It was an honor to join this online expert education. I’m not sure I can contribute resourceful resource, but I’ll join this discussion.
I like to surf on internet when there’s patient comes to our pharmacy and we don’t know yet what actually their problem. I know I should search on Google Scholar from my Android using Wi-Fi available connection or other clinical resourch before I suggest their medication, but in fact, lack of time made me search only from indication of the medicine from its label. Online is not always available. All patients not really have high education, so sometimes I’ve got to translate the medical language into the simplest local language. Yet, I don’t know the result from each medication I gave to them.
Apologize if its looks like irrelevant comment.
Hope you all enjoy this discussion as I do. Let’s the fun begin :)

Regards,
Yudha E. Saputra, BS in Pharmacy
Yogyakarta, Indonesia

lika papitashvili Replied at 6:52 AM, 14 Jul 2015

Thanks for the invitation. i am looking forward to the discussion

2015-07-14 8:41 GMT+03:00 Yudha Saputra via GHDonline <
>:

A/Prof. Terry HANNAN Replied at 6:57 AM, 14 Jul 2015

I suspect that many of us are ready for the fantastic "ride" this discussion will bring. It will be fantastic to have the Moderators inputs and observe the responses. A big thank you to the panellists for committing their time.

Mohammad Mehdi Karimi Replied at 9:03 AM, 14 Jul 2015

Dear Sir,I'll join the challenging discussion.Thank you so much.  Dr. M. Karimi

Auxilia Prof. Chideme-Munodawafa Replied at 9:05 AM, 14 Jul 2015

Good morning Sudip,
I am currently on vacation and traveling in between countries but should be
in the USA on 20th
Will join in the discussion if good WF available
Thanks for the material. Will read for preparation
Good day

Mohammad Ullah Replied at 9:48 AM, 14 Jul 2015

Thank you for the invitation. I am expecting to learn many things from the experts.

Regards,

Mohammad Ullah
------------------------------------------------------------
Technical Advisor (HIS) – Health Sector
Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH

Maxim Topaz Replied at 1:37 PM, 14 Jul 2015

Thanks for the invite- looking forward to the discussions!

--
Please join us at the fabulous H3IT: HOME HEALTHCARE AND HOSPICE
INFORMATION TECHNOLOGY CONFERENCE <http://h3it.org/>
http://h3it.org/
------------------------------------------
Maxim (Max) Topaz PhD, RN, MA
Postdoctoral Research Fellow
Brigham and Women's Hospital & Harvard Medical School
Phone: 267-994-2751
Website:* https://connects.catalyst.harvard.edu/profiles/display/Person/130004
<https://connects.catalyst.harvard.edu/profiles/display/Person/130004>*

George Otto Replied at 5:59 PM, 14 Jul 2015

Thank you for the invitation to this discussion.

Joris Van Dam Replied at 7:31 PM, 14 Jul 2015

Great topic, count me in!

Thx for the invite,

Osmán de Jesús Argüello Sequera Replied at 12:19 AM, 15 Jul 2015

Thanks for the invitation

I am in a special course, I will answer soon, and I love the initiative to
help build better care networks

Atte.

Benda Kithaka Replied at 8:57 AM, 15 Jul 2015

Dear GHDonline Team,

Thank you for the invitation. This is an interesting topic
with great promise for learnings from experiences from low
resource settings and best practice done in high income
countries.



Unfortunately I cannot join the discussions on as Kenya is
hosting the 1st Lady Conference starting this coming Sunday.
The 9th SCCA Cervical Breast and Prostate Cancer Conference
(19th - 21st July) for First Ladies. As an organisation, we
are involved in the Conference in offering Free Public
Screenings with other partners starting tomorrow - 15th
through to 21st July; and are making some oral presentations
on the 20th.



I will therefore try to join the discussions on the 23rd and
24th.



I am really excited to be on this platform and to share on
various topics. Keep up the good work,



Warm regards,

Benda


Benda N. Kithaka | Founding Member & Board Chair

Women 4 Cancer Early Detection & Treatment

Direct Line +254 724 635 680 | Email
<mailto:>


<mailto:>


Every Step Counts!


Phone: +254 (20) 261 8996 | Mobile: +254 717 117 446 | P.O.
Box 13263 - 00100, Nairobi - Kenya

Email: <mailto:>
| Website: <http://www.women4cancer.org/>
www.women4cancer.org




Please consider the environment before printing this email

Rachel Pohl Replied at 9:16 AM, 15 Jul 2015

I am interested in whether these digital resources provide an opportunity
for health providers to access information related to social determinants,
such as housing and food and income.

Can this panel address this, provide examples, or discuss how a platform
like the two being highlighted here can integrate public health and social
and economic information relevant to clinical care in settings...

Is this happening anywhere in the US? or internationally.

and...

can this be used as a platform for training...

thanks.

Manu Gupta Replied at 10:54 AM, 17 Jul 2015

Thanks for the invite. Looking forward for the discussion.

Joe Welfeld Replied at 10:56 AM, 17 Jul 2015

Thank you for the invite.

As a consultant and faculty member in DNP and Healthcare MBA programs, I expect the discussion to be extremely valuable.

Attached resource:

Zehra Ahmed Replied at 10:57 AM, 17 Jul 2015

Thank you for the invitation. I will indeed attend and contribute to the discussion. I am presently enrolled in a Masters in Instructional Technology at NYIT (2016 completion) with the intention of using the skills for developing eLearning projects. I have been creating small education projects within the course and would like to see how resources that are available could be incorporated further.
I look forward to the discussion.

Zehra Ahmed, PA-C, MBBS
Interim Program Chair & Assistant Professor
Department of Physician Assistant Studies
School of Health Professions
New York Institute of Technology
Old Westbury. NY

arnab paul Replied at 11:17 AM, 17 Jul 2015

Dear Rebecca,
Thanks for the invite. I am so looking forward to it for my professional growth, specially when my startup is entering into a Strategic tie-up. I hope to gain from and contribute to this discussion.

Best Wishes

Arnab
Co-Founder PatientPlanet

Luis Azpurua Replied at 11:44 AM, 17 Jul 2015

Dear Damir,

Thanks for the invitation.

Looking forward to engage into a fruitful discussion.

Usman Raza Replied at 12:28 PM, 17 Jul 2015

Looking forward...

Thomas Bauer Replied at 12:56 PM, 17 Jul 2015

Research has shown that 74% of all U.S. adults use the Internet, and 61% have looked for health or medical information on the Internet . Additionally, 49% have accessed a website that provides information about a specific medical condition or problem.” Clearly consumers of healthcare are seeking quality patient education information. Medline Plus is a wonderful resource of non-biased information that is produced by the National Library of Medicine, however, it does not appear to aggressively promoted.

Thomas Bauer Replied at 12:59 PM, 17 Jul 2015

Approximately 25% of the adult population does not use or have access to the internet. Consequently, digital answer is a key to reach some. However, according to some researchers reliance on digital resources has the potential of widening the reported disparity of outcomes by income

Lawrence Wasserman PhD Replied at 1:27 PM, 17 Jul 2015

Please include my name for serving on this community.

My focus is telehealth and mobile health and its role in patient engagement.

How to submit my participation.

Regards Lawrence Wasserman PhD

Bert Kollaard Replied at 2:08 PM, 17 Jul 2015

I am looking forward to contributing to the discussion next week and appreciate being part of the GHDonline community. I am actively involved and passionate about the intersection between healthcare and IT and especially MHealth, social media and the use of standard and predictive analytics to improve clinical practices and patient outcomes. The growth of wearable sensors in various healthcare settings and the flow of data this will be producing is especially interesting in this regard.

Further to Thomas Bauer's post about the use of online resources by consumers, a variety of sources report growing use of social networking sites by Healthcare Professionals (HCP's) for both personal and professional use. Survey results from QuantiaMD in 2011 showed upward of 90% of physicians reportedly using social media for personal activities and 65% for professional reasons. These percentages have surely increased since that time. See "Social Media and Healthcare" from the July 2014 issues of the Pharmacy and Therapeutics Journal for a good overview ( http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4103576/#b9-ptj3907491).

MARIO NEYSER VASQUEZ DOMINGUEZ Replied at 6:33 PM, 17 Jul 2015

I´ll be in the discussion. Thaniks

Samahel Joseph Replied at 7:37 PM, 17 Jul 2015

Thanks for this amazing initiative, I confirm my participation.

Samahel

Paul Nelson Replied at 8:07 PM, 17 Jul 2015

The diversity of experience is spectacular.

Paul Nelson, M.D.
Primary Physician
Omaha, Nebraska

Neil Pakenham-Walsh Replied at 6:10 AM, 18 Jul 2015

Dear all on GHD Expansion of Digital Clinical Resources

I would like to invite you to join a virtual
discussion on HIFA (Healthcare Information For
All), starting Monday 20th July. Our first
question, starting Monday, is especially relevant to this forum:

How can health research from LMICs be made more visible and accessible?

Please forward this message widely...

--

Read online:
http://www.hifa2015.org/meeting-the-information-needs-of-researchers-and-user...

Dear colleagues,

We are delighted to announce a major new thematic
email discussion on the global forum HIFA (20
July to 24 August) to explore how to meet the
information needs of researchers and users of
research in low and middle income countries. This
Healthcare Information For All discussion is
being held in collaboration with APAME
[www.wpro.who.int/apame/en/], COHRED
[http://www.cohred.org/], and with support from
The Lancet [http://www.thelancet.com] in the
run-up to the Forum 2015, the Global Forum on
Research and Innovation for Health, Manila, 24-27
August 2015 [http://www.forum2015.org/], held in
conjunction with the Asia Pacific Association of
Medical Journal Editors 2015 Annual Convention,
Manila, 25-26 August 2015 [http://apame2015.healthresearch.ph].

WHY IS ACCESS TO RESEARCH IMPORTANT?
The WHO Constitution 'enshrines the highest
attainable standard of health as a fundamental
right of every human being. The right to health
includes access to timely, acceptable, and
affordable health care of appropriate quality …
as well as the underlying determiinants of
health, such as … access to health-related eduucation and information.'

Increasing the availability of health research is
fundamental to global health and the progressive
realisation of the right to health.

Researchers, policymakers, health professionals,
and citizens need access to the full text of
peer-reviewed research, relevant to their
context, and in a language they can understand.

"Access to research" here refers to the ability
of individuals to find, retrieve and understand
primary and secondary research, as well as
analysis and commentary on such research.
(Primary research involves the collection of
original data, while secondary research involves
the synthesis of previous research, as in systematic reviews.)

CURRENT ACCESS: DRIVERS AND BARRIERS
There is a growing momentum towards free (and
open) access to research. Also, in the past 15
years there have been several important
initiatives such as HINARI, eIFL, INASP, AJOL and
the WHO Global Health Library, all of which help
to improve the availability of health research.

The trends are positive, but there are many
limitations and exclusions. There is a long way
to go before all, or even the majority, of health
research is freely available to all those who need it.

WHAT CAN BE DONE TO ACCELERATE PROGRESS?

1. How can health research from LMICs be made more visible and accessible?
2. What more can be done to make research freely available to users in LMICs?
3. How can research be made available in the
right language, both for producers as well as consumers of health research?
4. How can we improve access to different formats
required by different users in different contexts
(eg abstracts, full text of research paper, commentaries, policy briefs)?
5. How can we improve the availability and use of
health research in LMICs through non-traditional
dissemination channels (eg social media,
communities of practice, blogs, mobile phones)?

These and other questions will be explored on the HIFA forum.

The key points from all discussions will be
presented at a Special Session on Access to
Research at Forum 2015, organised by APAME, on 26
August, and will be taken into consideration for
any declarations that may emerge from the conference.

ACKNOWLEDGEMENTS
We are grateful to The Lancet, COHRED, and APAME
for supporting this discussion. We are also
grateful to Elsevier, The Lancet and mPowering
Frontline Health Workers for their ongoing
support for the HIFA Voices database
(hifavoices.org), where key points from the
discussion will be collated. HIFA is supported by
the British Medical Assocation and more than 30
health and development organisations worldwide.

Best wishes,

Joey Florencio F. Lapena (President, APAME)
Neil Pakenham-Walsh (Coordinator, HIFA)

Mukhtar Rezukani Replied at 8:01 AM, 18 Jul 2015

Thank you for the invitation, I'll join the discussion.
Mukhtar

NGENZI Joseph Lune Replied at 8:34 AM, 18 Jul 2015

I am pleased to share a presentation on the study we have conducted in
University teaching Hospital about

The Utilization of Online Bibliographic Databases by Medical Professionals
in Rwanda: Case of UTHK

http://www.medetel.eu/download/2015/parallel_sessions/presentation/day1/The_u...

Thank you

NGENZI Joseph Lune Replied at 8:47 AM, 18 Jul 2015

in 2012 some Rwanda Medical students have received tablet equipped with
clinical resources and Have participated in teaching medical students how
to access free medical apps for clinical resources



http://www.newtimes.co.rw/section/article/2012-11-01/59245/



My view more intervention in this domain is needed



Let me share an interesting article



http://www.biomedcentral.com/content/pdf/s12909-015-0377-3.pdf


Let me share the activity conducted by evidence based medicine in Africa


http://www.cebha.org/sites/default/files/130225%20CEBHA%20ToT%20workshop%20Ad...

Gary Parkes Replied at 10:44 PM, 18 Jul 2015

Thank you for the invitation. Internet is very variable here but I hope to follow the discussion and contribute where appropriate. I am new to UptoDate but it is already proving very useful even in real time but also for preparing tutorials.
We and many others joining this forum are in resource limited situations and I would say that in the summary portion of the text there could be a subheading ' resource limited situations' do this!

A/Prof. Terry HANNAN Replied at 10:50 PM, 18 Jul 2015

Gary, the lovely "temptation" of your psoting leads me to ask for an expanded description as to "how" UpToDate is proving useful? Often there is the "very useful adjectives however can you provide a more details? Even if they are only non measured "perceptions" of benefits

Damon Ramsey Replied at 11:43 PM, 18 Jul 2015

Looking forward to a very productive discussion and dialogue.

Damon Ramsey
University of British Columbia

Mwanaisha Seugendo Replied at 3:39 AM, 19 Jul 2015

Thank you i will participate as it touches directly the environment i work

Ronald Eveillard Replied at 5:58 AM, 19 Jul 2015

‎Thanks for the invitation.

Abiy Tamrat Replied at 11:56 AM, 19 Jul 2015

Thanks for the invite. Looking forward for the discussion.

Luke Smart Replied at 3:34 AM, 20 Jul 2015

It is a pleasure to join this discussion. In regards to the prevalence of digital clinical resources, the answer depends on the population (and end user) in question. The term "resource-limited settings" although convenient does not acknowledge the great variation of resources across care settings and referral levels. I work within the larger context of a low income country as defined by the World Bank. But my immediate work environment is a university situated within one of the few referral hospitals in the country. In this setting, approximately 3/4ths of my students are using some sort of digital clinical resource, loosely defined, and Almost 100% of my fellow faculty members use the same. One step lower in the referral chain decreases the daily use of digital resources substantially, and the use of digital resources by end-users in the lowest referral level is minimal.

Learners within the university use these resources to answer clinical questions posed by faculty or patients. The university library strives to improve competence in the use of digital resources in general, clinical tools being one such resource. The most common use of digital content remains the general internet search for clinical content, but there is a growing awareness and use of specific clinical resource apps, especially those that can be freely accessed such as Medscape. Current digital clinical devices do not always provide direct answers to clinical questions because the available diagnostics or treatments may not match those at hand, but the use of digital resources does provide a gold standard for comparison as well as alternate diagnoses in an ambiguous case. The true impact of such information is hard to quantify. At the least it sharpens critical thinking and at the most, it directly changes therapy and outcome for the patient on hand.

NGENZI Joseph Lune Replied at 5:18 AM, 20 Jul 2015

“The application of what we know will have a bigger impact on health and
disease than any single drug or technology likely to be introduced in the
next decade.” *Sir Muir Gray, Director, NHS National Knowledge Service*


Within this era of information there is a lot of Digital evidence based
research However how do we promote evidence based practice based on the
current available electronic resources?


In most of the developing countries they face different challenges linked
to access to electronic resources and utilization of evidence based
medicine electronic resources. (Access to some journals and some database
which require payment, limited and high cost of internet, culture of
reading, workload, limited training in this regard, limited utilization of
already subscribed resources, limited research publication…).


Most of the librarian in developing countries need capacity building to
move from paper based resources toward digital clinical resources within
hospitals and universities.


More continuous medical education is needed to integrate how to use digital
clinical resource at the point of care.


All of these challenges are the opportunities for intervention by providing
access to internet and capacity building within in-service and pre-service
health professionals and the promotion of open access journals and database.


Despite that we do have free access to digital electronic resources
available for developing countries are HINARI by World Health organization.
A collection of health and medical related journals and e-books is
available free of charge for low income countries.


http://www.who.int/hinari/en/


The number of internet users. Smart phone mobile owners are increasing on
daily basis and most of the digital divide gaps are being addressed which
provide new opportunities for expansion of the digital clinical resources

Thomas Bauer Replied at 9:32 AM, 20 Jul 2015

The price of computer tabelts have ebcoem reasonable compared to the many costs of low health literacy. Given this fact, has anyone provide "free of charge" tablets containing all required patient education to their patients with chronic health conditions?

Jodi Scarbrough Replied at 9:32 AM, 20 Jul 2015

1. How prevalent are digital clinical resources in resource-limited settings and in what ways are they being implemented? What effects have they had on the quality of care provided?

There has been a proliferation of mHealth/eHealth responses to global health in low income settings, from collecting data, to diagnostic tools, to training clinical health care workers, and many other use cases in-between. The primary issue with the applications, devices and tools is the lack of infrastructure to support them, and tie the data collected to a central repository so the data can be parsed accordingly. In many cases the infrastructure simply doesn't exist.

Further, in Vecna Cares' experience in global health technology in low resource settings, generating reliable baseline data is first and foremost the most important milestone. Once this is achieved, other interventions can be measured. How accurate is the denominator?

Thomas Bauer Replied at 9:34 AM, 20 Jul 2015

An excellent resource for free medical information is the National Library of Medicine's Medline Plus. This reseource is availble on the web and through a smartphone app

Attached resource:

Ellie Baron Replied at 9:54 AM, 20 Jul 2015

Many thanks for hosting this forum – looking forward to exchanging ideas with everyone.

UpToDate has been collaborating with the Global Health Delivery Project (GHD) to provide donated subscriptions to health care providers who deliver medical care or education in resource limited settings and cannot afford the subscription cost.

There has been much favorable qualitative feedback on this program. Data on topics searched has been illustrative of the great breadth of clinical questions that arise in resource limited settings – they include expected topics, such as infectious diseases, but also many other issues including depression, diabetes, obstetrical care, liver disease, etc. Synoptic content allows readers in the field to read a streamlined clinical approach which includes review of the most important articles in the literature – in some circumstances this may be more efficient than reading individual journal articles or textbooks which quickly become outdated.

We hope to obtain further quantitative information regarding the impact of UpToDate on the quality of health care as well as medical education in resource limited settings.

Ellie Baron, MD
Deputy Editor, Infectious Disease
UpToDate / Wolters Kluwer Health

NGENZI Joseph Lune Replied at 10:23 AM, 20 Jul 2015

Medline plus is a free database written for patients and their families and
friends in an easy language. However the content is available only in
international language (English and Spanish,...). How many people
understand international languages in resource limited countries ?

Some youth and medical students in low income countries have started
creating websites where the content is in the local language and those
initiative needs to be supported.

If we target rural communities who does not know how to read and write the
appropriate technology is voice programs such Health related radio programs.

It is interesting to see that most mobile phone even those who are not
smart phone are equipped with Radio FM channels.

Some developing countries are investing heavily in the youth and children
with digital laptop and this an opportunity to create clinical digital
content.

NGENZI Joseph Lune Replied at 10:38 AM, 20 Jul 2015

Very pleased to know the offer of UpToDate to low income countries. I would
be happy to know more details so that the donated resources are being used
at maximum.

Jorge Lazareff Replied at 10:50 AM, 20 Jul 2015

Congratulations to the organizers of this forum.
At the UCLA Center for World Health we are developing our program on internet based medical education in collaboration with Universidad Nacional Autonoma de Nicaragua (Managua). We are developing the curriculum around what the authorities at UNAN determine are the gaps that we can fill from and we do it with Spanish speaking faculty.
Language plays a very important role in any project aiming at improving medical knowledge. We all agree on that English is the Universal language of Medical Science, and as a well intentioned corollary we have assumed, wrongly, that every physician in the world has an adequate command of English. An immense volume of clinical experience is lost to us in this side of the divide by not having a chance to hear what the very knowledgeable clinicians in the other side have to tell.
Our Programm is still far from being perfect. The best series of presentations are on Critical Thinking in Medicine, which should not be confused with Evidence Based Medicine, and on How to Read and Write a Paper.
Nicaragua is the country with less resources in the continental America, second to Haiti, and still the lectures were delivered without interruption from UCLA to the UNAN auditorium, and more importantly, the students submitted their work to the lecturer through e mail. I say that not to minimize the technological gap but to emphasize on that it is not as deep as we fear.
To summarize. The concept of clinical teaching is broader than a set of specifics of a medical condition. The training of the physicians in every nation should start at the Medical School level. and yes, nothing beats communicating the nuances of diagnosis, treatment and thought in the mother language of our hosts.

Lucy Muniz Replied at 10:55 AM, 20 Jul 2015

Thank you for the invitation, Anything/anybody from LATAM?

Rob Wu Replied at 11:04 AM, 20 Jul 2015

It is a pleasure to join and learn from this discussion. My interests are in the use of digital clinical resources smartphone applications and their accuracy. My experience in their use in resource-limited settings is limited. From my scan of the literature, there is use of different online resources (Hinari, UptoDate, Pubmed) as well as mobile tablet resources. In some of the literature, it is hard to determine whether the use is for research or at the point of care though. Difficult to determine the prevalence in 'resource-limited' settings from the literature.
I could not find anything on the effects on the quality of care in 'resource limited' settings from my scan.

Leo Anthony Celi Replied at 11:08 AM, 20 Jul 2015

I want to take a step back and highlight 2 key issues. The first is fundamental to any innovation in healthcare, including digital clinical resources. A culture of quality improvement is necessary for a healthcare innovation. This pertains to how every member of the system, healthcare provider or not, is empowered and committed to improving processes and continuous learning. We can have all these educational and decision support tools available to providers, but if there is no commitment among the providers to constantly measure and improve the way care is delivered, then such an initiative will have limited value. Consider the 2009 report from the WHO on the use of medications in primary care in LMICs based on 679 studies from 97 countries. According to the report, less than 30-40% were treated according to existing clinical guidelines. Do we think we can "fix" this problem by providing digital clinical resources? How likely will we able to convince providers that they need adhere to evidence-based medicine?
The other issue that is worth pointing out is the reality that most clinical guidelines are formulated in the developed world. At times they are based on population studies performed most of the time in the developed world. In most occasions, they are based on expert opinions of clinicians practicing in the developed world. How do we know these apply to patients in LMICs? We need to establish a knowledge creation system that will inform the care of patients in LMICs. This is one of the driving force behind the Sana organization and the HST.936 course on global health informatics at MIT.

Enrique Castro Sanchez Replied at 12:01 PM, 20 Jul 2015

Hi all,

Superb audience!
1) As mentioned somewhere, just returned from a month in South Africa and Rwanda learning about development and implementation of enhanced nursing roles. Fantastic (and perhaps v unexpected) to see primary care nurses in Rwanda running their health centres using mobile phones for patient registration, symptom checker, stock management, activity data upload to central registry, etc. Really made me think about the

2) I have to agree with Elizabeth, bit disappointed about lack of nurses in the panel...

3) Thomas, also agree with you, I think we have got limited evidence about the impact of digital tools to address health literacy deficits/to support health literacy. I suppose we also have the issue of 'digital literacy' to consider on its own. I think the paper from Kayser et al is going to be a classic (http://goo.gl/1cPe2i)

4) At the Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London we have developed clinical apps and lately an electronic game aimed at modifying prescribing behaviours in doctors (have a look at the minimum viable version here http://goo.gl/i8veHy). My idea is once we demonstrate whether it offers any added benefit to traditional interventions, adapt it to LMIC to supplement existing training approaches. It runs on the most basic computer, and we could easily include cases of emerging infections (Ebola??). Players decisions are recorded secure and anonymously and we can therefore learn about the most effective factors altering clinicians' behaviour. We could add further gamification elements, etc.

Kind regards,

Enrique

Enrique Castro-Sánchez MPH RGN DipTropNurs PgDip DLSHTM
Lead Research Nurse
NIHR Health Protection Research Unit
In Healthcare Associated Infection and Antimicrobial Resistance
at Imperial College London, Hammersmith Campus, W12 0NN
Tel: +44 203 313 2732
www.imperial.ac.uk/hpruantimicrobialresistance/

Jasper Holthuis Replied at 12:07 PM, 20 Jul 2015

Also congrats to the organizers!



As a developer/producer/distributor of basic learning material (online) for
medical education I presume that my contribution is very limited.

Our program 'skills in medicine' has been developed together with the
'skillslab' of the Maastricht University (The Netherlands). A demo version
can been seen/evaluated at: http://www.skillsinmedicine-demo.com/ .

Regarding the discussion about languages: we are presently working on a
Brazilian/Portuguese version as well as a (Mexican)Spanish version.

This to facilitate educational institutes/organisations and whatever
involved in medical education/training.

We have also produced a book about critical thinking/doing (in English): the
title is 'Training Critical Appraisal of a topic' (ISBN 978-90-77201-53-4).

As this material is/has been developed in close collaboration with the
Maastricht University that has a vast collaboration with many Universites
abroad, I'm sure it could possibly suit your needs.

If you are interested please feel free to contact me:

Traci Wolbrink Replied at 12:41 PM, 20 Jul 2015

Thank you for inviting me to be part of this really exciting discussion!

I wanted to reply to the first discussion point: How prevalent are digital clinical resources in resource-limited settings and in what ways are they being implemented? What effects have they had on the quality of care provided?

I think that it is an exciting time to be thinking about digital resources. With the ever-growing reach of digital connectedness, the opportunities are endless and really beginning to explode from mobile decision support tools, to parent and patient educational videos, to helping mothers access transportation to safe delivery space, the opportunities for imparting care are enormous.

As one example of how digital tools are effecting quality of care, I have been working on a project called OPENPediatrics, a free-of-charge and open-access digital learning and social collaboration platform for clinicians caring for sick children worldwide (www.openpediatrics.org). Although still in the early adaption phase, we are currently being used in 125 countries and in over 800 hospitals. On the site are videos, protocols and opportunities for discussions with clinicians about best practices in common problems. By giving access to high-quality, peer-reviewed videos and protocols based on the practices in use at major pediatric centers worldwide, we are able to share freely and discuss the best practices around the world. All centers, regardless of resource capacity, can learn something from these resources and discussions. As an example, we have a video regarding how to access a central venous catheter. A hospital in Turkey described how they adapted the practice demonstrated in the video, and reduced their rate of central line infections. In Moscow, burn care practices were altered and improved based on a series of burn care videos available. By allowing providers to see how practices might be different in other areas, it allows rich internal discussions about how to alter one's own practices. And not only is there a one way transfer of knowledge, clinicians can also share directly alongside the videos in conversations about what might work and how the practices might be altered in their setting. This allows for a rich discussion relevant to actual clinical practice that the whole community can benefit from. As more hospitals share their practices and contribute to this growing resource, practice around the world can be improved.

Usman Raza Replied at 3:31 PM, 20 Jul 2015

This is great discussion with lots of useful insights. My exposure is
mostly limited to Pakistan, large part of which can be considered
resource-limited.
Since (I think) there is a general lack of understanding about the
infrastructure needed to support such initiatives (as Leo mentioned), most
of the activities here are isolated bits and pieces in the form e-health of
m-health projects funded for a short duration by one donor or the other.

The use of digital clinical resources or even a simple Google search for
any medical information by the medical community is limited. At the
undergraduate level, some medical schools (including the one where I teach)
have taken the initiative to introduce Problem-Based Learning, and also
attempted to increase the use of digital resources as part of this. What I
observed over the past 5 years, is that in the absence of a reasonable
incentive or motivation, the students seldom adopt this behavior. At
practice level, probably there is more felt need for having ready access to
digital resources, but the overall system does not contain any incentives
to promote the use of such resources when available.

Interestingly, I repeatedly find that the use of Facebook far exceeds the
use of any other website by doctors, students, general population or even
people whom one would consider unable to understand English.

Recently, an interesting regulatory change has occurred, with the medical
council announcing mandatory CME (finally) for all doctors who wish to
retain their practice license. I believe this policy change has tremendous
implications and opportunities. However, the council has restricted online
CMEs to 25% of total (may be due to concerns about
quality/transparency/accreditation).

Lastly, on gamification, Quiz Up <https://www.quizup.com/en>, seems like an
interesting model with some possible application in the medical field.

Alvin Marcelo, MD Replied at 5:10 PM, 20 Jul 2015

Thank you for the interesting exchanges.

I concur with Dr Leo Celi that ultimately, it is human capacity-building
that is needed -- and the technologies should be designed to ensure that
the "human" reforms happen.

Having said that, I can only imagine that if I were a primary care provider
(and I am not), I would already be overwhelmed with all the resources being
shared in this thread. There are so many innovations here and every one is
interesting!

How can such resources be organized so that they are systematically
delivered to the busy health worker all alone in an island in the
Philippines? Should these resources be competing for icon-space on her
smartphone interface or should the worker be given an "GHDOnlineAppStore"
to choose from (with guarantees that all of these apps from the store are
interoperable and of high-quality?)...

Ultimately, the Ministry of Health must answer this question. I think they
are our main target for this thread...Hope we also hear from them....

Elizabeth Glaser Replied at 5:16 PM, 20 Jul 2015

Hard to keep up with all the comments, so apologies if this question was already asked.

Are digital clinical resources being used to enhance the care provided by non-physician providers?

In LMIC as well as in rural areas of upper income countries, there are a dearth of physicians. As much as doctors in low resource settings may use clinical digital apps and the like, nurses, pharmacists and any physician extenders such as clinical officers might benefit most from access to such resources in lieu of physicians.

In my opinion, GHDonline missed an opportunity to offer an interprofessional panel on a subject that truly is relevant to ALL clinicians. That being said , I appreciate your expertise and hope that the moderator and panelists will address the value of this resource across a number of disciplines.

best regards

Elizabeth

A/Prof. Terry HANNAN Replied at 5:57 PM, 20 Jul 2015

Jorge Lazareff, this is a wonderful quote. "Our Programm is still far from being perfect. The best series of presentations are on Critical Thinking in Medicine, which should not be confused with Evidence Based Medicine, and on How to Read and Write a Paper. Nicaragua is the country with less resources in the continental America, second to Haiti, and still the lectures were delivered without interruption from UCLA to the UNAN auditorium, and more importantly, the students submitted their work to the lecturer through e mail. I say that not to minimize the technological gap but to emphasize on that it is not as deep as we fear."

A/Prof. Terry HANNAN Replied at 6:05 PM, 20 Jul 2015

Traci, right questions.
1. How prevalent are digital clinical resources in resource-limited settings and in what ways are they being implemented? Latest stats I have read ? from the WHO. At the end of 2016 7.4 billion mobile devices which is more than the population of the world!!
2. What effects have they had on the quality of care provided? Reports (some have been posted here today) indicate yes, no unsure. A 'technological evolution' in progress.

Benda Kithaka Replied at 7:06 PM, 20 Jul 2015

Dear Colleagues,

I am very excited to follow in the discussion, especially
since our work is in Kenya which is classified a low
resource setting.



According to a Communications Authority of Kenya (CAK)
report, Kenya had over 16.3 Million people with a mobile
device, and a staggering 26.1 Million internet users by
December 2014. It is also reported that 65% of all new
phones sales right now are smart phones.



Being the country that also championed the Mobile Money
revolution in the world through our award winning MPESA
Mobile Money Platform, I believe that the two platforms
offer a tremendous opportunity for e-health activities.



As the founder of an organisation that is championing the
simplifying of messaging for cervical cancer awareness in
Kenya, I would be interested to know what resources exist
out there in the developed nations for authoritative,
simplified e-health messages that we can re-package for
relevance and suitability for our low resource setting.



Look forward to your input.



Benda




Benda N. Kithaka | Founding Member & Board Chair

Women 4 Cancer Early Detection & Treatment

Direct Line +254 724 635 680 | Email
<mailto:>


<mailto:>


Every Step Counts!


Phone: +254 (20) 261 8996 | Mobile: +254 717 117 446 | P.O.
Box 13263 - 00100, Nairobi - Kenya

Email: <mailto:>
| Website: <http://www.women4cancer.org/>
www.women4cancer.org




Please consider the environment before printing this email

Benda Kithaka Replied at 7:15 PM, 20 Jul 2015

Dear Prof. Hannan,



Thank you, I love this. I will definitely check the
resources because it probably responds to my earlier
question.



To All,

On a separate note, I came across a new technology [at least
to me] during the ongoing First Lady 9th SCCA conference in
Kenya, by the Mobile ODT Team. The Mobile Colposcope [see
www.mobileodt.com <http://www.mobileodt.com> ] is a
technology that integrates the mobile capability of the
smart phone, and the capability for use as an imaging device
for VIA, and can also be used as a Mobile Colposcope for
Tele-medicine in cervical cancer diagnostics. What is even
more impressive is the data connectivity ability that this
device accords, as currently at the First Lady conference it
is being used for real time reporting on the public
screenings through VIA by various partners.



We are participating using the Pap Smear Tests therefore our
data is currently not loaded.



I have copied Ms. Yael on this email, a representative of
the Mobile ODT team, as she is in a better position to
expound on the technology, and also explain how the
technology works. Hopefully she can also join the forum and
add value to the conversations that are ongoing.



With kind regards all,

Benda


Benda N. Kithaka | Founding Member & Board Chair

Women 4 Cancer Early Detection & Treatment

Direct Line +254 724 635 680 | Email
<mailto:>


<mailto:>


Every Step Counts!


Phone: +254 (20) 261 8996 | Mobile: +254 717 117 446 | P.O.
Box 13263 - 00100, Nairobi - Kenya

Email: <mailto:>
| Website: <http://www.women4cancer.org/>
www.women4cancer.org




Please consider the environment before printing this email

David Aylward Replied at 10:52 PM, 20 Jul 2015

Well said Elizabeth.



>

Fredirick Mashili Replied at 11:35 PM, 20 Jul 2015

Very interesting discussions,

I echo what has been said by Leo Anthony regarding less involvement of LMIC during the process of creation of resources, be it clinical guidelines or online resources like the ones we are discussing now. While every thing has got a start a forward look should be on involving as much of LMIC academicians and practitioners in the process of material creation and all preliminaries in the making of digital online contents. I particularly think this is very important for two main reasons
1. To include in the resources what is exactly needed by practitioners in LMIC. but also to make sure the preferred way of communication in LMIC is also being featured.
2. To avoid crippling the LMIC health academics and practitioners (getting used to use resources that have been entirely created from developed world can eventually kill creativity in LMIC in the end having no original work from these countries) by involving them in the process of creativity and preparation

My thinking is that, a strong collaboration between developed world and LMIC in the process of creating digital online resources, will not only improve their use in LMIC but also build capacity among LMIC medical academicians and practitioners.

I believe the initiatives such as the one UpToDate started, will not only give free access to practitioners in LIC, but also will identify points of collaborations.

A great start.
Fredirick

Kee Park Replied at 12:13 AM, 21 Jul 2015

Thank you all for sharing your wealth of knowledge and experiences.
In Phnom Penh, the medical students, residents and faculty(including me) in the neurosurgery department use digital devices(smartphones) for searching the internet (mainly Google), sending and receiving images e.g. MRI, CT etc. and reading reference eBooks.
Second-hand smartphones are less than $200 and 3G data is cheap and reasonably fast, $5 for 2GB.
This is the extent of utilization of digital clinical resources. We do not use any applications for clinical decision support.
We are also not using any EMR apps although a group from USC is bringing a system to trial next month. It is called NotesFirst.

Dr. Leo Celi's comment about guidelines is spot on. The resources need to region specific. Applying US head trauma guidelines in Cambodia simply doesn't work. For example, we have no way to monitor intracranial pressure in Cambodia. Another example is the indications for head CT. With high percentage (almost 50% of surgeries) of epidural hematomas from low velocity unhelmeted(90%) moto accidents, we order CT based on mechanism rather than clinical presentation. By the way, in developed countries, the ratio of epidural hematomas to subdural hematomas is about 1/10 not 1/1. the guidelines need to be region specific and is only possible with collection of data.

A/Prof. Terry HANNAN Replied at 1:53 AM, 21 Jul 2015

Kee, this is a great posting. "Dr. Leo Celi's comment about guidelines is spot on. The resources need to region specific. Applying US head trauma guidelines in Cambodia simply doesn't work. For example, we have no way to monitor intracranial pressure in Cambodia. Another example is the indications for head CT. With high percentage (almost 50% of surgeries) of epidural hematomas from low velocity unhelmeted(90%) moto accidents, we order CT based on mechanism rather than clinical presentation"
This is why you need "effective data capture tools with iterative feedback to the end users" for clinical decision support. Your CT for head trauma guidelines is a very good example. There are recurring publications with evidence that with CT/MRIs there is much overuse (as well as underuse and inappropriate use) of such resources where "appropriate clinical assessments based on a correct history and examination can obviate the need to order these resources". With appropriate use resources, especially financial can be freed up or saved for more appropriate components of care delivery and prevention.
I have tried to present a balanced perspective on these issues in a recent paper-attached

Attached resource:

Luke Smart Replied at 4:27 AM, 21 Jul 2015

This has been a fascinating wide-ranging discussion about the variety of ways that digital devices can be used in relationship to health. I think that appropriate infrastructure, development, implementation, and effect will depend on the end user in question and their stated purpose for using digital content. So far the conversation has encompassed the use of digital content by patients (health education), students (how to best learn the field of medicine), providers (how do I diagnose this patient, how do I treat this patient), researchers (how can I better collect data), and educators (how can I educate medical students and/or patients). Clearly the infrastructure, applications, and content will differ according to the application and end-user in mind.

I would like to tackle the next suggested question. What barriers are prevalent in that limit large-scale uptake of digital clinical resources? What incentives are in place for healthcare systems to expand their digital clinical resources?

The implementation of digital clinical resources can be described along a cascade (as our several other programs). The beginning steps will be similar for all end users and purposes, but the later steps will vary widely depending on the type of digital clinical resource, the type of enduser, and the healthcare setting.

For a care provider who is looking for guidance on a particular clinical case, I would hypothesize the following cascade:

1) availability/affordability of digital device (phone, tablet, computer)

2) availability/affordability of connectivity for that device (e.g. internet access, network access)

3) information seeking behavior of the user (do they possess critical thinking skills, are they able to identify their own knowledge gaps)

4) technology literacy of the user (do they know how to find the correct digital content, do they know how to use the digital clinical resource to find the answer to their question)

5) availability of medical diagnostics/treatments (are the tests/treatments recommended by their resource available in their setting)

Barriers could be encountered at any step along this pathway. In many urban centers within LMIC, accessibility is not the primary problem. Rather, it is the ability of the user or the appropriateness of the content that inhibits the content from causing improvement in clinical care.

From my experience, there are little incentives to expand digital clinical resources in my setting. Most of the incentive resides within the providers own motivation to improve. I am sure that there are incentive programs globally, and maybe even locally, but I haven't heard about them or seen them affect the roll-out of digital clinical resources in my immediate practice settings.

Rob Wu Replied at 7:19 AM, 21 Jul 2015

Great discussion.I would like to build on Luke Smart's cascade of barriers.

1) Language of the content can be a barrier (Jorge Lazareff's comment).
2) I would also agree with Alvin Marcelo's issue of too many apps. From this discussion, there are many apps mentioned. The Google and Apple store have many apps. Having a few trusted high quality apps is key.
3) One of the big issues is time. If it is not easy and fast to get a high quality answer, the uptake will be low. While this could fall into #3 information seeking behaviour - it also speaks to the usability of the resources.

A/Prof. Terry HANNAN Replied at 7:47 AM, 21 Jul 2015

As a current GHDonline Moderator I am making a request that an attempt should be made with the postings on this discussion to integrate and summarise them into "Knowledge Resource" for future access and use.
Mentally this discussion is like winning the lottery on this topic.
A superb collaboration across the planet.

Jai Ganesh Replied at 7:54 AM, 21 Jul 2015

Can't agree more.

Jo Vallis Replied at 8:28 AM, 21 Jul 2015

I agree too, to summarising the discussion as a valuable resource.
Jo Vallis
Research Officer
NHS Education for Scotland

Ellie Baron Replied at 11:03 AM, 21 Jul 2015

Many thanks for the many interesting comments - have been enjoying perusing the skillsinmedicine demo as well as openpediatrics.org

Perhaps the greatest challenge for the UpToDate donations program has been how best to promote usage of UpToDate in resource limited settings – to ensure healthcare workers know that the resource is available, to help users understand the value and utility of the evidence-based medical information, and to change clinical behavior such that clinicians incorporate UpToDate usage into the day-to-day clinical work of caring for patients.

Other barriers have included technical limitations such as unstable internet access or inadequate availability of computers or handheld devices. Language limitations have not been a substantial barrier as many users are able to read in English even if it is not their first language; it is also possible to enter search terms in another language.

Ellie Baron, MD
Deputy Editor, Infectious Diseases
UpToDate / Wolters Kluwer

Leo Anthony Celi Replied at 11:04 AM, 21 Jul 2015

I will build on the comments from Eloy Marcelo, Usman Raza, Fredirick Mashili and Kee Park. The biggest problem is not about making digital clinical resources available not just to physicians but to all healthcare providers working in isolated environs. The issues we have to tackle head on are:
1. lack of infrastructure and culture to leverage the value from these digital clinical resources (and technology-based innovations in general) - The hope that a complex problem such as the lack of a system and culture of quality improvement will have a technological solution is very seductive. Failures and disappointments are inevitable. The quality improvement movement in the US took 30 years to gain traction from the publication of the Donabedian paper through the 1999 IOM report. How do we fast track such movement in LMICs? This is the only way to get the most value from, to sustain and to scale innovations in healthcare. We can keep addressing low-hanging fruits but, at the same time, we need to work on systems level problems.
2. content of available digital clinical resources may not be applicable to the LMIC setting - rather than making clinical guidelines formulated in the developed world to our colleagues in LMICs including the community health workers, shouldn't we assist them with building a knowledge system that is relevant to them?
By the way, do we have evidence in the developed world that these digital clinical resources have improved quality of care? At least in the medical informatics world, evidence only exists for computerized provider order entry as far as decision support tools. Perhaps adoption of POEs in LMICs will give us more bang for our buck as regards improving quality of care? I know I'm going off tangent here but I want us as a community to think long and hard how best to leverage technology to improve health outcomes.

Naglaa Arafa Replied at 3:33 PM, 21 Jul 2015

Thank you first of all for this incredibly rich discussion. I'm joining in quite late, but I do want to add (as a university lecturer in Egypt) that the teaching system here does not really encourage students to search for guidelines and incorporate them into clinical practice. The system emphasises rote learning from books, and evidence-based medicine is hardly practiced at all. As some members noted above, the culture of using up-to-date information (which may sometimes contradict the knowledge of more senior staff members) may not be present at all. This needs to be nurtured in LMICs.

Gary Parkes Replied at 10:14 PM, 21 Jul 2015

I am new to using UPto Date and finding it a very sueful tool to think about unfamiliar problems and as a teaching resource. But I totally agree that some of the guidance is useless in our setting in Nepal where investigations and resources are limited. Some collaboration between the now out of date Primary Surgery / primary anaestesia Series of books and perhaps TALC (teaching aids at low cost) could bear good fruit in adapting Western evidence to the LMIC setting (can anyone else suggest other collaborations?).

My other concern is that we are beginning to find that UTD is so authoritative that it may be a barrier to local innovation. For example we now use a method of CPAP with extremely low tech readily available equipment but it need research to confirm its efficacy. It seems to work but would the neonate have got better anyway?

Damir Ljuboja Replied at 12:43 AM, 22 Jul 2015

Wonderful discussion so far, everyone! Thank you for your continued contributions. I'd like to pose the next conversation topic to the group to continue to draw on the wide breadth of your experiences as physicians, nurses, pharmacists, and other healthcare professionals:

How can members of the medical community address the barriers to digital clinical resources that have been discussed thus far?

As a reminder, the entire panel will be summarized in a discussion brief once we come to a close after Friday, July 24. See here for more information about our discussion briefs - http://www.ghdonline.org/discussionbriefs/

Damir Ljuboja
Panel Organizer

Rehema Chande Mallya Replied at 2:55 AM, 22 Jul 2015

I agree with Mashili that there is a need of engaging health professionals from LMIC in the preparation and creation of materials into the various health and biomedical resources. In line with the above, awareness on the use of these resources is one of the prerequisite ingredients in CME. Moreover, familiarization on the available resources from various health institutions especially in remote access areas is a challenge. Therefore through collaboration a majority of people will be able to have access and utilize it into different activities such as research, teaching, learning and clinical aspect.

Pratap Kumar Replied at 3:22 AM, 22 Jul 2015

Dear all, a few thoughts from me as someone engaging non-physician cadres in LMICs on adhering to guidelines. I apologise for repeating other thoughts here, but there've been too many comments to go through each one.


1. Content must be created with nurses and clinical officers (physician's assistants) in mind, as they are the ones managing most primary care clinics in LMICs (India being an exception to some extent). As others have pointed out here, very little research into training and quality improvement has been done with these cadres in mind.


2. There needs to be room to adapt content to the local context. Even within one slum in a city there are clinics and clinicians with hugely differing capacities. If the content does not seem relevant because it talks about a PCR or X-ray or even a microscope, then uptake and application of the content is compromised. Therefore 'what-ifs' need to be part of the content/evidence/guidelines.


3. Format and design are hugely important considerations. Content for consumption on a mobile phone, booklet or a video need to be designed with the user/customer in mind. We're pioneering the use of templates as rubber stamps that are linked to training material.


4. Dual/multiple use for content. It's very limiting to say content is for training only. We're thinking of training content to be linked to treatment protocols and data collection for improving outcomes. Therefore concerted efforts are needed and partnerships are key!

Happy to hear from people interested in collaborating or help redesign existing content for use in low resource settings. Pratap AT Health-E-Net.org

Jodi Scarbrough Replied at 7:51 AM, 22 Jul 2015

2. What barriers are prevalent in that limit large-scale uptake of digital clinical resources? What incentives are in place for healthcare systems to expand their digital clinical resources?

Looking specifically in resource poor settings, basic infrastructure is the limiting factor to the large uptake of digital clinical resources. Reliable access to electricity, internet or cell phone connections and/or local servers. While there is a proliferation of digital clinical devices, some of them relatively low tech, the recording and reporting of information is an important element of the process. Without effective methods of reporting and benchmarking it is difficult to measure success or failure. Low resource settings don't need more devices or piloting of devices, they need reliable infrastructure and a foundation on which to integrate the technical resources as well as a reliable and effective way to record results and transfer data. Patients need access to their personal health records, clinicians need access to longitudinal patient data and the administrators need access to healthcare trending data. Without access to high quality, reliable data on the patient populations, it is impossible to measure the impact of digital solutions.

A/Prof. Terry HANNAN Replied at 8:44 AM, 22 Jul 2015

Jodi, thanks for the "light bulb" moment as I believe these references are valid.
I will upload the files tomorrow from work as the upload from home does not complete the process.
1. Tierney WM, Kanter AS, Fraser HS, Bailey C. A toolkit for e-health partnerships in low-income nations. Health Aff (Millwood).29(2):268-73. Epub 2010/03/30.
2. Tierney WM., Kanter AS., Fraser HSF., C. B. Establishing partnerships to promote eHealth in developing countries: Lessons from Africa. Health Aff (Millwood) 2009 (in press). 2009.
3. 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 Annual Symposium proceedings / AMIA Symposium AMIA Symposium. 2006:529-33. Epub 2007/01/24.

Elizabeth Glaser Replied at 8:50 AM, 22 Jul 2015

I very much agree with Prata and Jodi's comments.

Are we including telemedicine as a digital resource? If so. better infrastructure can allow physicians to remotely consult on challenging cases and provide support to colleagues in remote areas. Where there is no doctor there is usually a nurse or clinical officer , sometimes acting as the sole clinician These providers can use digital resources to likely improve the overall consistency and quality of care.

Re local context: although guidelines may differ somewhat by country, typical pediatric care usually followed according to the Integrated Management of Childhood Illnesses in teh past - is that no longer true?
There is a digital version of the IMCI, has anyone tried to use the computer adapted version in their country rather than developing new resources?

A/Prof. Terry HANNAN Replied at 9:19 AM, 22 Jul 2015

Elizabeth I like it when people like yourself make these postings about human clinical resources. Using the appropriate tools e.g. telemedicine a health care system can function without doctors. We did this in Kenya where much of our initial work was carried out by nurses, nurses aides and ultimately patients with great success.
Getting the tools in place and training the coal face care givers with evolving "information management tools" it is remarkable what can be achieved.
As pointed out some time ago to me and others. What is the cost and time to educate and train a doctor? Then per unit of human resource how much can one doctor do e.g. with an epidemic of millions of people with illnesses such as ADIS or NCDS?

Ellie Baron Replied at 9:46 AM, 22 Jul 2015

Many thanks for these comments.

Some UpToDate content has been developed to address health care in resource-limited settings, and the editorial staff is open to further feedback from users in these settings. Development of such content can be a real challenge because even within such settings, access to diagnostic and therapeutic tools is variable. Also, users have indicated they appreciate information regarding clinical management in ‘best-case’ scenarios as it helps with decision-making re referrals and choice of tools that would be most useful to obtain locally.

Applications for donated subscriptions may be found here: http://www.uptodate.com/home/uptodate-donations-program

Ellie Baron, MD
UpToDate

Maggie Sullivan Replied at 10:54 AM, 22 Jul 2015

Before the panel ended, I wanted to include an article recently published in the Journal of Nursing Scholarship regarding nursing practice and health IT. Here's a comment from the authors: Many times, information technology systems are not designed to match the workflow of nurses. Systems built with redundant or impertinent reminders may be ignored. System designers must study which reminders nurses find most useful and which reminders result in the best quality outcomes.

Abstract
PURPOSE:
To report additional mediation findings from a descriptive cross sectional study to examine if nurses' perceptions of the impact of healthcare information technology on their practice mediates the relationship between electronic nursing care reminder use and missed nursing care.

DESIGN:
The study used a descriptive design. The sample (N = 165) was composed of registered nurses working on acute care hospital units. The sample was obtained from a large teaching hospital in Southeast Michigan in the fall of 2012. All eligible nursing units (n = 19) were included.

METHODS:
The MISSCARE Survey, Nursing Care Reminders Usage Survey, and the Impact of Healthcare Information Technology Scale were used to collect data to test for mediation. Mediation was tested using the method described by Baron and Kenny. Multiple regression equations were used to analyze the data to determine if mediation occurred between the variables.

FINDINGS:
Missed nursing care, the outcome variable, was regressed on the predictor variable, reminder usage, and the mediator variable impact of technology on nursing practice. The impact of healthcare information technology (IHIT) on nursing practice negatively affected missed nursing care (t = -4.12, p < .001), explaining 9.8% of variance in missed nursing care. With IHIT present, the predictor (reminder usage) was no longer significant (t = -.70, p = .48). Thus, the reduced direct association between reminder usage and missed nursing care when IHIT was in the model supported the hypothesis that IHIT was at least one of the mediators in the relationship between reminder usage and missed nursing care.

CONCLUSIONS:
The perceptions of the impact of healthcare information technology mediates the relationship between nursing care reminder use and missed nursing care. The findings are beneficial to the advancement of healthcare technology in that designers of healthcare information technology systems need to keep in mind that perceptions regarding impacts of the technology will influence usage.

Attached resource:

Leo Anthony Celi Replied at 11:18 AM, 22 Jul 2015

I want to expand what we mean creating clinical guidelines for patients in LMICs. I am not referring to recommendations with regard to tests and treatments that are not locally available. I am alluding to evidence-based medicine specifically for patients in LMICs. Tests and treatments shown to benefit patients in the US and Western Europe may not necessarily be effective to other populations. This is due to heterogeneity of treatment effect.
So what does creating evidence-based medicine relevant to patients in LMICs entail? It requires the performance of more research - pragmatic clinical trials and observational studies - in LMICs. It means leveraging the digital health data collected in the process of care be performing secondary analysis for comparative effectiveness research, pharmacovigilance, cost studies, etc. This is, of course, a major effort and requires a paradigm shift. What we are saying is that we will not hand over our evidence-based medicine to our colleagues in LMICs. Instead, we will assist them with creating their own evidence-based medicine.
We will be offering an open course on secondary analysis of digital health data at MIT next year. Just like our course on innovations in global health informatics, we will be offering it at no cost to partner universities. The goal is to build human capacity on the ground for health data analytics in order to build evidence-based medicine that is relevant to LMICs.

Kee Park Replied at 12:45 PM, 22 Jul 2015

What barriers are prevalent in that limit large-scale uptake of digital clinical resources?


A well-intentioned eHealth company decides that their flagship clinical resource product should be provided to Cambodian healthcare workers. With much fanfare, they introduce their devices and train the local personnel who are thrilled to get devices presumably for free. After some time, the utilization of the content wanes and we are all wondering if there was any true benefit.
What happened?
Maybe googling is much easier and faster than the resource app. Maybe the “free” app has additional features or renewal that require payment.
I believe the main reason is because the content is not in context of local population and capabilities. To illustrate, a typical Cambodian neurosurgeon does not consider the “current” recommendations from a well-known Handbook of Neurosurgery to be relevant. He adapts what he has been taught (usually in a developed country) to the situation in Cambodia and tries his best to manage the patients often with excellent results. Thus he has very little motivation to seek out the latest level 1evidence. He is also unlikely to spend the time to collect data for analysis given his need to earn a living to support his family.
The current Cambodian residents in neurosurgery, however, are different.
They are much more motivated to incorporate digital resources and collect data.
In order for them to succeed, I think Jodi’s comment is apropos:
“Low resource settings don't need more devices or piloting of devices, they need reliable infrastructure and a foundation on which to integrate the technical resources as well as a reliable and effective way to record results and transfer data. Patients need access to their personal health records, clinicians need access to longitudinal patient data and the administrators need access to healthcare trending data. Without access to high quality, reliable data on the patient populations, it is impossible to measure the impact of digital solutions.”

In a country like Cambodia where resources are limited and medical records are essentially non-existent, it is difficult to imagine proliferation of digital clinical resources without addressing the medical records/data issue. Perhaps GHDonline can organize a panel on how best to support research in LMIC.

Aaron Beals Replied at 1:20 PM, 22 Jul 2015

@Kee: Excellent, concrete example of the challenges. In the situation you're describing, are the barriers generational? That is, will the Cambodian residents continue to use digital resources & data collection when they finish their residency? Or will they follow the model of their more experienced peers?

From what others have said and as you describe, the mapping of recommendations to the context of local population and capabilities is a critical component here.

Edward Krisiunas Replied at 1:20 PM, 22 Jul 2015

Good evening..

I have only been reading these replies as I was in transit to Vietnam...

Thank you to Leo and others for reiterating the local context...having
been traveling to countries addressing waste disposal issues since 1995, I
quickly learned to look and listen as I was not in the USA anymore nor
could I contact my local suppliers/contacts and have what I needed the
next day via a courier. That is one element that needs to be expanded upon
- clinical interventions discussed via digital resources must also take
into account the ability to procure a product / device if mentioned. That
requires a good mobile /wired network ( which by the way Vietnam has) and
a good network of professionals who are communicating with each other as
needs/products/services arise. I see that now with the procurement of
autoclave bags..for a high income country, not an issue. Here at $2.00 for
a 60 liter bag, not sustainable and an new autoclave goes unused because
of it. The responders to this discussion all have similar stories I am
sure and I could many more as well. The level of risk tolerance varies to
so many issues including health care in LMIC..something one may not
phahthom "digitigally" - family of 5 on a 125cc motorbike..See:
http://www.economist.com/news/middle-east-and-africa/21654659-dirty-sheets-an...

I also beleive we need to interface more with the mobile telephone
industry in each country...as I had previosly stated before this group
started the discussion, I am constantly amazed at the availability and use
of mobile phones in the most challenging environments. If these people are
able to pay their bills with M-PESA ..we need to leverage this tool for
healthcare as well.



My additional interest and challenge is promoting safe injection practices
such as with auto disable syringes and proper sharps disposal...great that
WHO and the CDC are promoting this practice but you have to be able to
afford them as well as countries have to make health care a priority.

I'd be happy to network my contacts in various countries with MIT...just
let me know who should be contacted.

Thank you again for the opportunity to share my experiences.

Luke Smart Replied at 2:58 PM, 22 Jul 2015

How can members of the medical community address the barriers to digital clinical resources that have been discussed thus far?

Reliable infrastructure is a nonnegotiable for digital clinical resources to have any measure of effect. Advocacy to this effect from clinicians may assist in government/industry/hospital investment in that direction. Infrastructure alone is necessary but not sufficient. I agree with the many of you who have already stated that adapting resources to local settings is an essential step to follow.

Marie Teichman Replied at 5:04 PM, 22 Jul 2015

Thank you all for such a rich discussion this week! Due to the volume of responses we have received in the Expert Panel, we have compiled daily briefs for your use prior to the completion of the full Discussion Brief. I will be posting Monday - Wednesday's briefs in succession and then Thursday and Friday's at the end of their respective days.

Marie T.
Community Coordinator
___________________________________________________________________________________________________________________________________________________________________

Monday’s discussion surrounded the question of how digital clinical resources (DCRs) are implemented, their prevalence in resource limited settings, and the effects they have on the quality of care provided.

A primary issue with applying DCRs in low-resource settings is the lack of infrastructure to support them. Digital resources often lack the ability to collect data in a central repository for equal distribution among users in the community. A vital first step towards expanding DCRs usefulness is enabling systems to generate a reliable baseline of data for all users.

Clinical guidelines are also most often formulated in the developed world, leaving little suggestion for application in developing countries. This raises issues around how current DCRs can provide a standard for comparison as they do not always provide direct answers to pertinent clinical questions. To foster a culture of quality improvement in care delivery, providers around the world must be empowered and committed to improving process, access, and continued learning through DCRs.

The importance of integrating the use of DCRs at the point of care into medical education programs is also a major limiting factor in expanding their use, given that many digital resources lack availability in various languages. One suggestion was the use of voice technology or health radio programs to distribute information to those who may not have access to internet or print sources. Most mobile phones, even those that are not smart phones, have FM radio capabilities providing a form of communication that could reach health professionals in remote locations.

An interesting quote from panelist Luke Smart of Weill Bugando School of Medicine, Mwanza, Tanzania:

The term "resource-limited settings" although convenient does not acknowledge the great variation of resources across care settings and referral levels. I work within the larger context of a low income country as defined by the World Bank. But my immediate work environment is a university situated within one of the few referral hospitals in the country. In this setting, approximately 3/4ths of my students are using some sort of digital clinical resource, loosely defined, and almost 100% of my fellow faculty members use the same. One step lower in the referral chain decreases the daily use of digital resources substantially, and the use of digital resources by end-users in the lowest referral level is minimal.

Resources shared for free medical information access online:
· Medline Plus: http://www.nlm.nih.gov/medlineplus/
· HINARI: http://www.who.int/hinari/en/
· Pubmed: http://www.ncbi.nlm.nih.gov/pubmed
· OPENPediatrics: www.openpediatrics.org

Marie Teichman Replied at 5:07 PM, 22 Jul 2015

Tuesday’s discussion surrounded the barriers that limit the large-scale uptake of DCRs and the lack of incentives for health professionals to expand these resources.

A large issue for many LMICs is the lack of local infrastructure to support the expanding use of DCRs. The availability and affordability of digital devices and connectivity are strong concerns for many potential users around the world, creating a large barrier to accessing these resources.

One major aspect of using DCRs that is often overlooked is the importance of human capacity building and the necessity to ensure that human reforms are happening. Many panelists highlighted that there are few incentives for health professionals past personal growth, to using the digital resources available to them.

The guidelines and information that DCRs provide is sometimes not applicable to settings that lack many basic resources, calling for regional specificity when creating or updating DCRs. The need for LMIC and end user input towards the creation of DRCs pushes for resources that contain exact information that local practitioners need and are available through locally preferred communication techniques. This interactive feedback will also avoid crippling LMIC health academics and practitioners who can be overwhelmed by the excess of outside resources.

Panelist Luke Smart brought up the idea of a cascade implementation for developing DCRs:
“1) Availability/affordability of digital device (phone, tablet, computer)

2) Availability/affordability of connectivity for that device (e.g. internet access, network access)

3) Information seeking behavior of the user (do they possess critical thinking skills, are they able to identify their own knowledge gaps)

4) Technology literacy of the user (do they know how to find the correct digital content, do they know how to use the digital clinical resource to find the answer to their question)

5) Availability of medical diagnostics/treatments (are the tests/treatments recommended by their resource available in their setting)

Barriers could be encountered at any step along this pathway. In many urban centers within LMIC, accessibility is not the primary problem. Rather, it is the ability of the user or the appropriateness of the content that inhibits the content from causing improvement in clinical care. “

Marie Teichman Replied at 5:09 PM, 22 Jul 2015

Wednesday’s discussion encompassed what the medical community must address in order to tackle the barriers to DCRs that have been discussed this week.

The two major points focused on today branched from previous discussions on the need for information relating to local contexts and the lack of infrastructure in LMICs. All of the participants agreed that the need for LMIC health professionals’ engagement in the creation of these digital resources would be the best way to ensure and improve their use. The important point of making sure that the DCRs allow for ease of use by a range of health professionals including nurses, clinical officers (PA’s), and pharmacists was also mentioned.

While useful, resources such as UpToDate only provide “best case scenarios” in order for local health professionals to analyze and implement according to their personal settings. The provision of evidence based medicine for patients in LMICs would require research in the form of clinical trials and observational studies on location. This approach focuses on assisting local workforces in the creation of their own evidence-based medicine. *

Panelist Jodi Scarbrough shared a “lightbulb” moment for some participants when discussing the importance of infrastructure for the use of DCRs:

“Low resource settings don't need more devices or piloting of devices, they need reliable infrastructure and a foundation on which to integrate the technical resources as well as a reliable and effective way to record results and transfer data. Patients need access to their personal health records, clinicians need access to longitudinal patient data and the administrators need access to healthcare trending data. Without access to high quality, reliable data on the patient populations, it is impossible to measure the impact of digital solutions.”

While infrastructure is a strong place to start, it alone is not efficient enough for the level of change that is necessary. Panelists mentioned the importance of advocacy from clinicians towards government/industry/hospital investment possibilities that could aid in the expansion of DCRs.

* Panelist Leo Celi mentioned a course that will be held at MIT surrounding the secondary analysis of digital health data and building human capacity on the ground for health data analytics, in order to build evidence-based medicine relevant to LMICs.

Luis Azpurua Replied at 7:32 PM, 22 Jul 2015

Hi all, great discussion so far.

Locally in LATAM there are barriers to digital clinical resources.

The english language is a formidable barrier. I have seen many health care workers declining to participate into a research or to adopt a CME programs because of the language barrier. Sharing the information in the native language (spanish / portuguese) would be of great help. I would like to know more about The UCLA and the UNAM initiative.

Governance, Lack of reliable information, lack of health IT platform: in Venezuela most of the public hospitals have paper medical records. If you are lucky, you can find a computer with an Excel progam used to register some of the data. There is little reporting and access to information is very limited.
So we see it as a huge opportunity for designing and implementing health IT projects. But first of all the government (health authorities) has to create the country's standards in order to know how are we going to play the game.

Finally, I´m interested on the open course on secondary analysis of digital health data. Could it be possible to take it as an online course (MOOC)? This could be a great way to reach out to many people in many countries.

Rob Wu Replied at 8:20 PM, 22 Jul 2015

The discussion is fascinating, and the list of barriers daunting.

Focusing on using point of care or educational resources for clinicians – like UptoDate or DynaMed, I find it encouraging that there is some use in LMICs from posts as well as the literature. Widespread use and content specific to LMICs could be a great medium to long term goal.

I am interested in knowing whether digital clinical resources like UptoDate are a reasonable starting point in the short term. I did not know previously about UptoDate’s program for LMICs or resource limited topics. It is a good starting point or a different platform (such as open source) desired?
I am trying to figure out if a few good apps are what is required - or is it a bunch of language and context specific digital clinical resources.

Traci Wolbrink Replied at 10:53 PM, 22 Jul 2015

To also address the topics: What barriers are prevalent in that limit large-scale uptake of digital clinical resources? What
incentives are in place for healthcare systems to expand their digital clinical resources? How can members of the medical community address these barriers?

I don't want to repeat conversations and completely agree with previous discussions about lack of access/affordability to devices, Internet and support of local government to create locally applicable resources, and add that the following problems:
1. The large amount of information available as well as multiple platforms/applications/stores to access these resources can also hinder our ability to find and share resources.
2. Lack of research and true data in what strategies are most effective in various regions in delivering information through DCRs.
3. Remaining "current" is challenging with the multitude of sites, all with differing password and variability in how often they update resources.

I wonder if we might be able to tackle some of these problems is we really created more communities of practice in medicine to help curate and highlight the best content and sites at any particular time, and if together focused development on strategies that work and systematically apply these to build out appropriate content, technologies and delivery modalities. We are now more connected than ever and yet still cannot find and share information well with each other.

This panel is a great example of how we can quickly and easily discuss what amazing resources are out there and potentially reach out to one another to work together on various projects. I know that I am certainly enjoying learning about new projects that I was previously unaware.

Sudha Jayaraman Replied at 11:35 PM, 22 Jul 2015

Maybe we need a wikimedicine or wikiresearch that is a crowdsourced platform that is updated and consensus based and that can objectively highlight controversies without seeming too biased. Would that sufficiently disrupt the current proprietary sites and journals and offer transparent way of reaching accurate and peer reviewed content that is accessible from anywhere?



Sudha Jayaraman MD MSc


>

Anthony Philippakis Replied at 8:54 AM, 23 Jul 2015

It's a real honor to be asked to participate in this important discussion!

One of the biggest opportunities for growth that I see is in decision support technologies. Physicians often make very large, binary decisions that have huge downstream impacts on people's lives. For example, as a cardiologist two examples that come to mind are
1) should a patient get a defibrillator --it can be life saving, but can also lead to complications and increased costs.
2) should a patient get anticoagulated --it can prevent a stroke, but also can cause a severe bleeding event.

Right now, we have only crude tools to make these decisions, in both the developed and the developing world. Much of this is driven by a lack of reimbursement for decision support. I feel that this is one of the greatest opportunities for governments to enact change.

Naomi Muinga Replied at 8:56 AM, 23 Jul 2015

Very interesting discussion here and I agree with all the points raised.

What I can add(maybe someone has mentioned already) is:

Infrastructure is a major barrier. This can be overcome by provision of well equiped resouce centers/libraries and the provision of affordable internet. Power issues are also a major barrier as you need electricity to be able to access the resources.

Age of health workers and IT capacity is a key factor to consider. It is possible that the older workforce are less IT savvy meaning they are not able to fully utilise digital recources. On workforce still, many LICs are also faced with the challenge of staff hence one of the reasons commonly given as to why they do not access information is that they are too busy.

Digital resources require appropriate infrastructure to be able to be used efficiently in addition to training in terms of how to use the resources and how to appraise the material.

I have attached here a link to a paper we wrote assessing the access to and value of information for health workers in Public hospitals in Kenya that shows that health workers do own mobile phones and a good number have access to computers but challenges still exist when they need to access information.

Attached resources:

Naomi Muinga Replied at 8:58 AM, 23 Jul 2015

Also, maybe an incentive to access information would be a way to convert access to digital resources and time spent reading these resources into CPD points...

Jo Vallis Replied at 9:22 AM, 23 Jul 2015

Dear All,
Thank you very much for this very stimulating debate. I have learned a great deal.

I tend to agree with those who say that digital clinical resources should be driven by endusers, especially in LMIC where, it seems to me, high quality evidence is of little use unless there are the resources (staff, investigations, drugs, internet, smartphones, airtime etc.) to follow. Spending time listening deeply and getting to know the context is also crucial, as concluded by our Zambian partner, Mr. Consider Mudenda, who recently visited Scotland on our attached Scottish Government-funded Small Grant project on 'Strengthening emergency care communications' at a remote, rural hospital in central Zambia. Mr. Mudenda, an ICT specialist, was competitively selected to present his attached paper at a UK Department for International Development (DFID) Digital for Development Workshop (East Kilbride, Scotland, June 2015). His paper was very well received by the DFID audience. Here are his conclusions:

"A multitude of experts who came to work with us in Zambia in ICT projects enjoyed. Some came with an explicit, pre-set agenda, others with an open mind, to observe and to learn.

Periods spanned 1-2 weeks, several months or years. Effectiveness varied. Some laboured and their work evaporated immediately they left. Others laboured and a Legacy continued to exist and bloom.

Our experiences shows that in order to reach enduring results, it is necessary to spend considerable time observing and then serve in the community in accordance with what was learned. Those who were able to observe the needs of the local community, and did accept all the arrangements made by local community, earned a love and respect of the local community. Thus the first key approach is to observe. It takes time to look, listen and really try to understand what is happening."

Thank you.

Attached resources:

Kee Park Replied at 10:33 AM, 23 Jul 2015

@Aaron Beals: As their seniors have done, the new generation will still need to adapt "textbook" knowledge (I would include DCR here) to the resource limited settings unless their economic situation improves dramatically. We have emphasized the need to collect data and conduct research as this in the ONLY way to understand the epidemiology , needs, quality and cost of neurosurgical conditions in Cambodia. We are currently using a customized FileMaker Pro database with ability to input data (including images) using smartphones to collect information on all neurosurgical admissions at a major government hospital. We have over 1000 patients now.
The residents are highly adept with IT. The key was to show the importance of research to a group of eager residents who see performing surgery as the holy grail. By organizing conferences in Phnom Penh with neurosurgeons from overseas including their neighbors from ASEAN the residents began linking data to improved health. For example, head injury data in Vietnam lead to helmet laws for moto riders resulting in reduction in head injuries in HCMC. A few residents "got" this and have each started on their own projects. One recently presented his abstract about epidemiology of spine trauma in Cambodia at a spine conference the US. He is still smiling!

Attached resource:

Leo Anthony Celi Replied at 12:31 PM, 23 Jul 2015

I will echo Kee Park's recommendation on what should be done on a national level which is to create an infrastructure to make clinical research a priority. The idea that research is a luxury that is only possible in developed countries is absurd. I would argue that research is even more important when resources are limited to figure out what works and what are potentially harmful. The value of a learning healthcare system that is supported by a robust information technology is even greater in LMICs.

Om G Replied at 1:10 PM, 23 Jul 2015

Excellent observations regarding use of appropriate locally relevant care.

There is also the tactic of preparing for the next most likely technology.
In many, many cases that is, or will be SMS.

Marie Teichman Replied at 4:48 PM, 23 Jul 2015

Hello everyone,

Here is the brief from today's discussion so far. Keep up the great work for our Expert Panel's last day tomorrow!

Marie T.
Community Coordinator
_______________________________________________________________________________________________________________________________________________________________

Thursday’s discussion built on the barriers to using DCRs and the incentives that the health community can implement to tackle these hurdles while still expanding DCRs use.

Language barriers can diminish the confidence of some health professionals to participate in research or adopt CME programs, decreasing their opportunities for knowledge expansion. The age of health workers along with their IT capacity can also drastically affect the acceptance of new systems and technologies into routine use. Staff time is precious and not often available to spend learning how to use various resources, making ease of use and minimal complexity key factors to DCRs implementation.

The multitude of sources and information hubs that house varying levels of appropriate, up to date intelligence are often overwhelming to potential users. A program or platform that could curate and highlight the best content across vast amounts of sources would allow for better development and delivery of current information around the globe. In LMICs, high quality evidence is of little use unless there are specific resources to follow while relating to local context and language.

Overcoming infrastructure issues is a difficult task where the lack of reliable information, funding to clinical research, and health IT platforms due to absent government attention needs to be addressed. There are open opportunities for designing and implementing health IT projects that can overcome many of these barriers.

Panelist Leo Celi shared his recommendation for national participation in the realm of research:

“I will echo Kee Park's recommendation on what should be done on a national level which is to create an infrastructure to make clinical research a priority. The idea that research is a luxury that is only possible in developed countries is absurd. I would argue that research is even more important when resources are limited to figure out what works and what are potentially harmful. The value of a learning healthcare system that is supported by a robust information technology is even greater in LMICs.”

Auxilia Prof. Chideme-Munodawafa Replied at 7:39 PM, 23 Jul 2015

Good afternoon and night to those ahead of Cleveland. Its my second attempt to post a comment on GHDonline, why? because I am a BBC( Borne Before Computers) as my students call me and the posting kept disappearing somewhere but I am glad at least my IT director call us senior citizens Migrators! This means keeping on trying until one gets it!
The point I am making is about senior citizen users of technology since quite a few of us are still out there at point of care.
However, having said that , the use of digital resources at various levels in healthcare can easily be accommodated by us senior citizens provided user
friendly gadgets and processes are adopted, for example the use of cellphones at point of care for various programs such as patient education, treatment adherence and even research can be adopted. It is quite common to find a grant mother of 60 years and above even all the way to the 80's speaking several times a day to their grand children all over the world on a cell phone whether smart phone or not. So this means starting by technology already in use and easily available to both healthcare providers and patients.
Some cell phone providers are already working with some universities in Zimbabwe by supplying students with tablets/ ipads to receive lectures on line as well as stay in touch with the schools.
I see the use of cellphones at point of care with very reasonable resources required.
As for telemedicine that was mentioned earlier, this requires more resources to set up and for training both ends and would not necessarily receive priority by governments in low resource budgets
I just want to thank all contributors and say that I have learned a lot. Remember I am a transformer and will slowly catch up in discussions

Om G Replied at 12:15 AM, 24 Jul 2015

There is a new Open Data Standard emerging that might help. Sharing
diagnosis, therapy and outcome while protecting personally identifiable
information should have been the foundation of every proprietary system out
there. Hopefully that will change soon.

Bruce Dahlman Replied at 12:48 AM, 24 Jul 2015

Dear friends,


I have not had time to review all the postings but appreciate the lively discussion on many points of the importance of supporting front-line primary care health workers especially with both valid and relevant information. I have been working on a solution to these needs from my perspective as a primary care educators for family medicine in Kenya for the past 10 or more years.



The result is the Digital African Health Library which is due to be launched next week from Nairobi to the Kenyan market and thereafter, other countries. You can visit at: http://digitalhealthlibrary.net<http://digitalhealth/> for more information.


Perhaps I can give a few distinctives of the research (2008-10 unpublished Master's in Health Professions Education thesis and follow-on study from Rwanda 2009) that has gone into development and my personal observations while in this development:

- the needs of clinicians working with patients at the front-line is a significantly different need of information than the researcher uses (Medline and HINARI)

- types of clinical decision support information needed is closely tied to the cadre using the material - nurses, clinical officers, pharmacists, medical officers, family doctors, etc.

- most management decisions by these cadres is currently authoritarian based - they need to access what their Ministry of Health recommends from appropriate guidelines. Moving to an evidence-based decision support paradigm is important over time; but can only be accomplished with accompanying educational interventions within formal educational programs in collaboration with the authority-based purveyors of information.

- therefore, relevance of the material to the setting (Africa in our case) is very important - we have approached Ministry of Health to utilize their clinical guidelines and when we move to additional countries, will seek the same collaboration

- there are many categories of information that are needed and no one resource fits all uses: handbook, guideline, formulary, differential diagnosis generator, emergency care, continuing education materials, etc.

- information that is available at the point of care vastly increases the decision affecting care for that patient; waiting to "look it up", be it on internet, home computer or library textbooks, is often too remote to affect care for the patient whose condition prompted the question asked

-information is preferably held "off-line" - data services, for all the improvements, are still not reliable and inexpensive enough for the average front-line worker to utilize, and becomes more of an issue the more rural and remote you go.

- searching for information must be integrated across resources - there is little time for the look-up function

-ideally, "personally validated" information that is sought and found can be "bookmarked" and personalized for later use.



Additionally, there is no "free lunch". The work, and therefore value, that is added by information publishers and aggregators to ensure relevance and validity and to make information easy to access and use requires someone's effort which require cost/funding. Our approach is to ask the user to pay a modest subscription cost and simultaneously ask the proprietary content providers and aggregators who add the value, to steeply discount their costs to us so that we can provide decision support resources for majority world needs - and these partners have continued to be very generous to see our mutual goals realized.



Although only available in Kenya to start, we anticipated working through local Country Partners who will engage their local Ministry of Health to be sure the "hyper-relevant" country- specific guidelines are available when roll-out occurs for them.



Lastly, from my 20+ years of serving and teaching in East Africa, I have found that use of information is most dependent on: the humility of the user to acknowledge they don't know and therefore, desire to learn; the clinician's compassion for the patient to want to make their care better to the point of taking time to find an answer to a patient-prompted clinical question, and, the persistence to find an answer with whatever information is available. We at the Digital African Health Library will do our best to optimize the last factor, but the first two factors remain the bedrock of improved outcomes.



Thank you.



Yours together for Health Information for All,



Bruce Dahlman MD MSHPE FAAFP

Director, Digital African Health Library, Nairobi, Kenya

Head, Kabarak University Department of Family Medicine, Kabarak, Kenya

Timothy Simard Replied at 8:54 AM, 24 Jul 2015

Dear Colleagues:
A great panel discussion on an important topic for everyone everywhere in fact.
Bruce, I look forward to learning more about your project. Congratulations and good luck with your launch.
Sincere thanks to all.
Tim Simard
CEO
Anthurium Solutions, Inc.
POET a Patient Care and Medication Management Enterprise Platform

Traci Wolbrink Replied at 8:58 AM, 24 Jul 2015

To answer today's question: Are there any examples or case studies of digital clinical resources that have been implemented on
a national scale? What lessons can we learn from their success?

I wanted to highlight a project called D-tree International, led by Marc Mitchell from the Harvard School of Public Health. The project vision is to make relevant clinical protocols available at point of care to improve care. His work has been in Tanzanai, Zanzibar, Sri Lanka, Benin and India to date. As an example of a project implemented on a national scale, here is info about D-tree's Safer Deliveries project (taken from their website at: http://www.d-tree.org/)

"In Zanzibar, working in collaboration with the Ministry of Health, Jhpiego and with funding from the Bill and Melinda Gates Foundation, we have established a system to reduce the 3 delays in care seeking behavior for pregnant women. We have equipped traditional birth attendants (TBAs) and community health workers (CHWs) with tools to register and screen pregnant and postpartum women and their newborns. We organized local transport providers and negotiated prices in advance for the routes to health facilities and tied the system together with mobile money to allow the providers to pay for the critical transport. To date, 225 health workers have registered over 10,000 women in the program and we have seen facility delivery rates increase from the lowest baseline of 30% (Pemba) to 77%.

To read more about D-tree’s Safer Deliveries project, please visit the following links: http://www.africanstrategies4health.org/uploads/1/3/5/3/13538666/mhealthvol5_..."

I think this project highlights may of the key issues discussed this week. Using relevant, locally appropriate protocols, enabling access at point of care and working together with local partners and government.

steve ollis Replied at 10:22 AM, 24 Jul 2015

Thank you Traci for highlighting this project.

Wanted to provide an updated hyperlink as well (now correctly points to page 52 of the USAID mHealth Compendium)

http://www.africanstrategies4health.org/uploads/1/3/5/3/13538666/mhealthvol5_...

Would be happy to share our final project report with any of those interested as well as our thoughts for the future of this program now that we have been fortunate enough to receive an award under Saving Lives at Birth Round 4 (https://savinglivesatbirth.net/news/14/08/01/round-4-award-nominees-30-awards...)

Specifically, relative to this discussion one of the key lessons from this was taking the time to involve the health system at various levels throughout the project. This included discussions and ongoing engagement with the Ministry of Health Integrated Reproductive and Child Health unit, Health Management Information Systems unit and Directorate of Planning as well as the Development Partners Group, Maternal Health Task Force, other partners strengthening the quality of care at the health facilities both nationally and locally as well as the District Health Management Teams, health facilities, Shehas (ward leaders), taxi drivers, community health workers and traditional birth attendants (even those who ended up not being part of the program), as well as Zantel and Etisalat (our telecommunications and mobile money partner).

Rebecca Weintraub, MD Replied at 4:07 PM, 24 Jul 2015

Many thanks to our panelists and community members who have shared their insights and expertise with us throughout the week. It has been tremendous to see all your comments and contributions.

While the discussion continues, a brief summary of some key points shared today:

Friday’s discussion focused on projects and case studies of DCRs that have or will be implemented on a national scale.

Important points that were brought to light encompass the fact that needs vary between different health professions and locations, bringing back the issue of local context from earlier this week. The need of clinicians within LMICs is different than the information used by researchers and collaboration is necessary between both groups in conjunction with Ministries of Health to construct a cohesive set of clinical guidelines. No one resource can fit all potential uses however, it is important to have integration between resources in order to decrease time needed to find an answer. Making sure that the resources allow for offline use makes information always available at the point of care and is critical towards making decisions that affect care for the patient.

In gratitude,
Rebecca

Damir Ljuboja Replied at 6:02 PM, 24 Jul 2015

Thank you everyone for a lively discussion! As the organizer of this panel, I ask that those of you who participated and observed please take a few minutes (~less than 5) to complete this quick survey on your usage of digital clinical resources. The data I collect will be included in the discussion brief and will help improve the community's knowledge of which resources are used and how they impact clinical care.

Here is a link to the poll: https://ghdonline.typeform.com/to/TpdLaM

And here is a direct link to the general report of the poll (shows aggregate results thus far): https://ghdonline.typeform.com/report/TpdLaM/GaIW

Thank you very much!
Damir

Damir Ljuboja Replied at 4:22 PM, 27 Jul 2015

Many, many thanks to our exceptional panelists, and all of our community members who participated in this incredibly rich discussion. We greatly appreciate the insights everyone has shared, and look forward to continuing to discuss these important topics in the coming weeks.

We will be working on a Discussion Brief to summarize the key points from this Expert Panel, and will share details as soon as that is available on the website.

Mean Reatanaksambath Replied at 10:08 PM, 1 Aug 2015

Any one make a summary as result of this discussion? Sambath

Juanita Fernando Replied at 10:31 PM, 2 Aug 2015

Hi,

I think the following for online professional learning about family violence from Australia is also useful. The site is open access and has been used in the UG medical curriculum. I trust everyone finds this useful:
http://www.pactsproject.org/

I'd love to be kept informed of your feedback.

Cheers
Juanita

Damir Ljuboja Replied at 12:05 AM, 3 Aug 2015

I am currently working on a discussion brief that will summarize the panel; I will post here as soon as it is available. For a day-to-day summary, please look at Marie's posts (99, 100, 101, and 113).

Thank you for your continuing interest in this important topic!

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Panelists of The Expansion of Digital Clinical Resources and GHDonline staff