Introduction
Disparity in quality of care is increasingly recognised as important causes of excess mortality and morbidity in acute healthcare internationally. In South Asia, services essential to the management of acute conditions—surgical, medical and critical care—are becoming increasingly available in the region, given the rising burden of non-communicable disease. Data from LMICs—although limited—suggests that outcomes for acutely unwell patients are poorer when compared with high-income countries (HICs).1 2 Increasingly, the inability measures continuous information to evaluate routine care and empower stakeholders to identify priorities for improvement is acknowledged as an important missing link in health system infrastructure.3
In HICs, national evaluation of outcomes, benchmarking of quality indicators and patient experience are driving care improvement and the way resources and services are delivered in acute care.4 In low-income and middle-income countries (LMICs), the lack of reliable facility level and national information has hampered attempts to continually evaluate the quality of care, hindered implementation of quality improvement initiatives and disempowered clinicians from identifying local research priorities. There has been little investment in health systems infrastructure or training for clinicians and administrators seeking to evaluate care in LMICs5 (figure 1).3 5 6 In addition, systematic information pertaining to patient experience and recovery following acute or critical illness is virtually non-existent in LMIC settings.7–9
Existing pathways and bottlenecks for information flow and proposed enhanced systems following mHealth platform implementation for acute and critical care.
While there is much in the literature to recommend what data should be collected,7 10 11 there is limited practical advice or examples on how day-to-day clinical information can be successfully captured, especially in overstretched and under-resourced LMIC settings.1 It is noticeable in HIC settings that healthcare providers and researchers have increasingly turned towards technology and digital surveillance in order to achieve the breadth and saturation of continuous information needed to improve care. The worldwide digital boom in accessible mobile technology and internet connectivity over the last 5 years has been most pronounced in South Asia and regions of sub-Saharan Africa.12 Digital (mHealth) tools to connect remote communities, most notably in health promotion and primary disease prevention, have been shown to have an impact on patients’ self-education and adherence to treatment. In contrast to these community settings, application of similar systems in acute and tertiary care in LMIC have been less well explored.9 13 14 Instead, disparate, paper-based systems persist, with patient records remaining ununified as patients move through the healthcare system, not only delaying the delivery of clinical care but also hindering efforts by clinicians seeking to prognosticate, benchmark and improve care.15 Complex routes to admission, heterogeneous populations, diverse patient journeys and the need to synthesise often high volumes of clinical and laboratory information from multiple sources further hinder efforts to apply technology in the acute setting, especially in LMICs.
To be effectively adopted within health systems, such innovations must harmonise with existing workflows, empower users, minimise user risk, optimise use of existing resources and augment evidence-based clinical management.4 9 12 The ability to integrate with existing or scaled national health information programmes is also essential if technologies are to be transferable with future traction beyond the existing infrastructure. These onerous requirements -often underestimated even in HIC- can seem insurmountable in resource-limited settings, where existing barriers to the adoption of such systems include cost, variable technology infrastructure and a perceived lack of value among busy clinicians.1 14 In addition, overburdened frontline staff are often unable to engage with such systems, perhaps due in part to the perceived enormity of behavioural change, task shift and burden of data capture that is potentially required.1 14 Furthermore, frontline clinicians also highlight the limited opportunities available to develop the necessary skills to heuristically evaluate care improvements in their healthcare facility.16
In this article, we draw from our experiences on designing, implementing and evaluating a clinician-led national digital mHealth information platform in acute care settings in Sri Lanka. We aim to share lessons on how successful engagement of clinicians in development and evaluation of the platform can help overcome the potential barriers to adoption described above. We also consider how this experience in Sri Lanka is now informing implementation and scaling of the platform in Pakistan, and how the methodology has potentially wider relevance for others seeking to address the information deficit for improving acute care in other LMICs.
