Digital Health in Response to COVID-19 in Low- and Middle-income Countries: Opportunities and Challenges.

COVID-19 has pulled back the curtain on health system fragility to expose persistent and deepening inequities worldwide. The limited capacity of low- and lower-middle income countries (LMICs) to respond to the pandemic and its impact on the health of populations - particularly the most vulnerable - presents a marked challenge. In this context, countries face the enormous task of rethinking the way essential services will be delivered.

Reimagining Health Data Exchange: An Application Programming Interface-Enabled Roadmap for India.

In February 2018, the Government of India announced a massive public health insurance scheme extending coverage to 500 million citizens, in effect making it the world's largest insurance program. To meet this target, the government will rely on technology to effectively scale services, monitor quality, and ensure accountability. While India has seen great strides in informational technology development and outsourcing, cellular phone penetration, cloud computing, and financial technology, the digital health ecosystem is in its nascent stages and has been waiting for a catalyst to seed the system.

Reducing communication delays and improving quality of care with a tuberculosis laboratory information system in resource poor environments: a cluster randomized controlled trial.

Background: Lost, delayed or incorrect laboratory results are associated with delays in initiating treatment. Delays in treatment for Multi-Drug Resistant Tuberculosis (MDR-TB) can worsen patient outcomes and increase transmission. The objective of this study was to evaluate the impact of a laboratory information system in reducing delays and the time for MDR-TB patients to culture convert (stop transmitting).

E-health systems for management of MDR-TB in resource-poor environments: a decade of experience and recommendations for future work.

Introduction: Multi-drug resistant TB (MDR-TB) is a complex infectious disease that is a growing threat to global health. It requires lengthy treatment with multiple drugs and specialized laboratory testing. To effectively scale up treatment to thousands of patients requires good information systems to support clinical care, reporting, drug forecasting, supply chain management and monitoring.

Implementing medical information systems in developing countries, what works and what doesn't.

Global Health Informatics is an emerging field, as demonstrated by several substantial and widely used electronic medical record (EMR) systems along with the emergence of mobile based or"mhealth" systems. We describe here many of the practical lessons we have learned from implementing systems in a wide range of challenging environments over the last decade. Some requirements, like data backups, skilled staff and local leadership are universally important.

Full impact of laboratory information system requires direct use by clinical staff: cluster randomized controlled trial.

Objective: To evaluate the time to communicate laboratory results to health centers (HCs) between the e-Chasqui web-based information system and the pre-existing paper-based system.

Methods: Cluster randomized controlled trial in 78 HCs in Peru. In the intervention group, 12 HCs had web access to results via e-Chasqui (point-of-care HCs) and forwarded results to 17 peripheral HCs.

E-health technologies show promise in developing countries.

Is there any evidence that e-health-using information technology to manage patient care-can have a positive impact in developing countries? Our systematic review of evaluations of e-health implementations in developing countries found that systems that improve communication between institutions, assist in ordering and managing medications, and help monitor and detect patients who might abandon care show promise. Evaluations of personal digital assistants and mobile devices convincingly demonstrate that such devices can be very effective in improving data collection time and quality. Donors and funders should require and sponsor outside evaluations to ensure that future e-health investments are well-targeted.

Personal digital assistants to collect tuberculosis bacteriology data in Peru reduce delays, errors, and workload, and are acceptable to users: cluster randomized controlled trial.

Objectives: To evaluate the effectiveness of a personal digital assistant (PDA)-based system for collecting tuberculosis test results and to compare this new system to the previous paper-based system. The PDA- and paper-based systems were evaluated based on processing times, frequency of errors, and number of work-hours expended by data collectors.

Methods: We conducted a cluster randomized controlled trial in 93 health establishments in Peru.

Using the e-Chasqui, web-based information system, to determine laboratory guidelines and data available to clinical staff.

13% of all drug susceptibility tests (DSTs) performed at a public laboratory in Peru were duplicate. To determine reasons for duplicate requests an online survey was implemented in the e-Chasqui laboratory information system. Results showed that 59.

Assessing effects of the e-Chasqui laboratory information system on accuracy and timeliness of bacteriology results in the Peruvian tuberculosis program.

We created a web-based laboratory information system, e-Chasqui to connect public laboratories to health centers to improve communication and analysis. After one year, we performed a pre and post assessment of communication delays and found that e-Chasqui maintained the average delay but eliminated delays of over 60 days. Adding digital verification maintained the average delay, but should increase accuracy.

Scale-up of multidrug-resistant tuberculosis laboratory services, Peru.

Over the past 10 years, the Peruvian National Tuberculosis (TB) Program, the National Reference Laboratory (NRL), Socios en Salud, and US partners have worked to strengthen the national TB laboratory network to support treatment of multidrug-resistant TB. We review key lessons of this experience. The preparation phase involved establishing criteria for drug susceptibility testing (DST), selecting appropriate DST methods, projecting the quantity of DST and culture to ensure adequate supplies, creating biosafe laboratory facilities for DST, training laboratory personnel on methods, and validating DST methods at the NRL.

A web-based laboratory information system to improve quality of care of tuberculosis patients in Peru: functional requirements, implementation and usage statistics.

Background: Multi-drug resistant tuberculosis patients in resource-poor settings experience large delays in starting appropriate treatment and may not be monitored appropriately due to an overburdened laboratory system, delays in communication of results, and missing or error-prone laboratory data. The objective of this paper is to describe an electronic laboratory information system implemented to alleviate these problems and its expanding use by the Peruvian public sector, as well as examine the broader issues of implementing such systems in resource-poor settings.

Methods: A web-based laboratory information system "e-Chasqui" has been designed and implemented in Peru to improve the timeliness and quality of laboratory data.

Information systems for patient follow-up and chronic management of HIV and tuberculosis: a life-saving technology in resource-poor areas.

Background: The scale-up of treatment for HIV and multidrug-resistant tuberculosis (MDR-TB) in developing countries requires a long-term relationship with the patient, accurate and accessible records of each patient's history, and methods to track his/her progress. Recent studies have shown up to 24% loss to follow-up of HIV patients in Africa during treatment and many patients not being started on treatment at all. Some programs for prevention of maternal-child transmission have more than 80% loss to follow-up of babies born to HIV-positive mothers.

Evaluating the impact and costs of deploying an electronic medical record system to support TB treatment in Peru.

The PIH-EMR is a Web based electronic medical record that has been in operation for over four years in Peru supporting the treatment of drug resistant TB. We describe here the types of evaluations that have been performed on the EMR to assess its impact on patient care, reporting, logistics and observational research. Formal studies have been performed on components for drug order entry, drug requirements prediction tools and the use of PDAs to collect bacteriology data.

Development, implementation and preliminary study of a PDA-based tuberculosis result collection system.

Partners In Health (PIH) and its sister organization in Lima, Peru, Socios En Salud (SES), treat a majority of multidrug-resistant tuberculosis (MDR-TB) patients in Peru, in conjunction with the Peruvian National TB Program (NTP). Monthly bacteriology tests, which must be collected from health establishments located across this major city, are an integral part of this treatment. Currently, a SES employee visits each health establishment to collect this information by hand, process it and type it into an electronic medical record system (PIH-EMR).

Adaptive control of a variable-impedance ankle-foot orthosis to assist drop-foot gait.

An active ankle-foot orthoses (AAFO) is presented where the impedance of the orthotic joint is modulated throughout the walking cycle to treat drop-foot gait. During controlled plantar flexion, a biomimetic torsional spring control is applied where orthotic joint stiffness is actively adjusted to minimize forefoot collisions with the ground. Throughout late stance, joint impedance is minimized so as not to impede powered plantar flexion movements, and during the swing phase, a torsional spring-damper control lifts the foot to provide toe clearance.