A Case for Standardization in Global Health Technology
The imperative for interoperability
In a village in sub-Saharan Africa, a frontline health worker pulls out her cellphone. For her, the apps on her phone are a critical link to the systems she uses to do her job. At any given time, she is juggling between a myriad of technologies. She uses an app that allows her to monitor her patients’ pregnancies; she also uses the electronic information systems for the local hospital (to which she must provide regular records of her patients and health-related data), another app developed by an NGO to provide helpful nutritional information to patients, and a SMS program for HIV positive individuals. Yet, when it comes to actually accessing and utilizing this patient information, the lack of synchronization between these technologies results in a labyrinth of mismatched information systems that inhibit easy access to the information she needs to do her job each day. Moreover, she is becoming frustrated with the sheer number of different and frequently changing technical interfaces. Shouldn’t all this technology be making information more easily accessible instead of locking it behind more doors? Isn’t there a better way?
Shouldn’t all this technology be making information more easily accessible instead of locking it behind more doors? Isn’t there a better way?
The Need
This anecdote highlights the imperative need for interoperability in global health technologies. The frontline health worker in the above example used multiple technologies to serve varying purposes. Mobile tech has shaped solutions to global health challenges in new, powerful ways. Unfortunately, a critical issue is that these systems cannot communicate and share information. This results in health care data, essential for patient care and disease surveillance, being scattered between different technologies as well as causing countless redundancies in official records. In order for mobile technologies to reach their potential in transforming global health, standardization and interoperability must be achieved.
What is standardization?
Have you ever thought about why your cell phone works anywhere in the world with cell reception? You may have to pay an arm and a leg for it, but you can make calls. You can thank international standards for that. Imagine not being able to use your ATM card at any machine because it didn’t fit in the slot or it couldn’t be read by the machine. And can we talk about USB drives? Imagine the bundles of wires and plastic we would need to cart with us everywhere just to access text files, let alone connect to other devices without USBs.
Standardization is the story behind the aforementioned examples. The British Standards Institution defines a standard as:
“In essence, a standard is an agreed way of doing something. It could be about making a product, managing a process, delivering a service or supplying materials — standards can cover a huge range of activities undertaken by organizations and used by their customers.” (Source)
Examples of standards in our everyday life also include FDA approval for pharmaceuticals, USDA meat standards, certified organic, internet protocols (IP), the email address format (name@domain.com), and university accreditation. Standards have the potential to save individuals, companies, and governments time, money, and hassle.
Global Health Technology and Standards
As the story of the frustrated health worker loaded down with uncommunicative apps and electronics illustrates, an abundance of global health technology exists, most of which serves a niche market. Many different products are built using different underlying technologies, resulting in their failure to communicate with each other. Fortunately, the big players in the global health space (including the World Health Organization) are beginning to recognize this issue and organizations are working together to address the need.
Standards can convey significant advantages in digital global health. These include:
· Open platforms: A standard is not necessarily open source. However, when an open source platform becomes an industry standard, there are powerful economies of scale. Any time someone builds something new using an open source technology or programming language, it becomes part of a public repository and anyone else can use it and build from it. Not having to constantly re-invent the wheel is huge.
· Innovation: Any standard, but particularly an open source standard, can lower the barrier of entry to new innovation. If there are standards, an innovator can be reasonably certain that by conforming to those standards, his or her developments can be accessed by the broader customer base.
· Collaboration and efficiency: Standards create a common language that allow folks to collaborate on projects and build from each other’s work.
· Modularity: Modularity is essentially a state where the components of a system can be disassembled, separated, and recombined with relative ease. These sub-units, or components, can be developed independently of the whole and then “plugged in” or added on top of a technology. A digital example of modularity are plug-ins that you can download for software — for example, ad blockers or translators on your browser. The underlying software was built by one organization but an add-on module was built by another person. In this way, global digital health has the potential to modularly expand, building additional capabilities that can integrate with the original.
· Communication of data: Standards would allow for data to be shared across different systems, instead of being siloed within their individual technologies. This has enormous repercussions on the individual patient care and also on high-level disease surveillance. (Suggested further reading here)
How are standards implemented?
So does someone just sit around and decide what a standard should be? Well, actually sometimes yes, but usually it is more complicated than that. There exist official organizations whose job is to define standards — these include American National Standards Institute (ANSI), the National Institute for Standards and Technology (NIST), etc. The United States alone has an estimated 600 organizations dedicated to developing standards, and countless others exist internationally.
It’s important to consider the implications of how and by whom standards are created. If they are created by these large governing bodies, they have the advantage of being legitimized. This results in de jure standards, which means by law. However, a frequent downside is that the the discussions, debate, and compromise necessary to establish standards takes a long time. Default standards can naturally evolve when enough “big players” in a space implicitly agree on conventions. These are de facto standards, which while not codified into any sort of law or formal consensus, are generally agreed upon. For example, de facto standards can evolve when an organization solves a technical problem in a particularly elegant way (interesting example here).
Challenges in Global Health Standards
The global health space poses unique challenges for standardization. No de facto or de juro standards have yet emerged due to the lack of governance and fragmented nature of the landscape. In terms of governance, there is no central body. Granted, certain organizations emerge at the forefront, most notably the World Health Organization (WHO), and also USAID, the Bill and Melinda Gates Foundation, etc., and these such organizations do have the ability to lend credibility and support to a standardization effort. However, the sprawling and decentralized nature of USAID, WHO, and other governing bodies means that they are slow to act and to reach agreement on standards would be a significant undertaking. Further, there are a multitude of actors — funders, implementers, non-profits, NGOs, research centers, and universities from all over the world. These organizations are often working on very related projects but separated by geography and language.
Additionally, the tight budgets of most non-profits do not lend well to the overhead cost of changing procedures. In a standards war, there are inevitably winners and losers, and if a standard is adopted that doesn’t align with what an organization is currently doing, it’s a painful and costly process to change (can you think of the chaos the U.S. would be thrown into if we needed to change a standard, for example, our measurement system to metric?). If a standard emerged that was not aligned with what a non-profit was currently doing, it’s likely that organization would not be able to make the conversion — and society would lose their contribution.
Moreover, there are serious intellectual property rights implications. A distinct advantage is had by someone who owns the patent to a recognized standard. It can be beneficial to a company who can charge a premium to consumers who are forced to buy their non-standard item (like the iPhone’s chargers). Fortunately, most global health organizations don’t rely on patients — which encourages the use of open source solutions.
Can you think of the chaos the U.S. would be thrown into if we needed to change a standard, for example, our measurement system to metric?
Moving towards standardization in digital global health
Already there exist open source platforms that are widely used — these include OpenMRS, RapidPro (RapidSMS), DHIS, and more. An organization established in 2013 called OpenHIE (Open Health Information Exchange) is working to create an architectural framework for interoperability in health data. The community evolved from an effort in Rwanda to connect the country’s health systems together. As the demand for such interoperability and connectivity grew, the movement expanded to the rest of the world. OpenHIE’s explains their framework through this image:
In the framework, data flows between where it is stored to where it can be used — and newly collected data can flow up to be aggregated and then back down to the point of care level. The idea is that point-of-care providers, be they doctors looking at a patient’s individual health record or a non-profit mobile messaging system, can have access to (and feed information up into) the wealth of health data available. The interoperability layer acts as a central exchange that allows these different systems and technologies to talk to each other.
A World With Global Health Technology Standards
It’s incredibly exciting to see some convergence in standards. Possibly the most compelling example is DHIS2, which is estimated to cover an astounding 1.3 billion people. It has been used and supported by USAID, PEPFAR, The Global Fund, Norad, and the University of Oslo. Perhaps the convergence to a system that stretches across entire health systems is indicative of the direction global health is heading. That is, eliminating silos (like malaria, TB, maternal health programs) and instead recognizing the interconnectedness and interdisciplinary aspect of health and wellness and enabling broader health systems strengthening.
If the technologies used by frontline health worker at the beginning of this post were interoperable, her story would read quite differently. She could be able to travel to her patients’ homes and pull their medical health records up on her mobile device. Then she could make notes on that record, and transfer it seamlessly to the records in the hospital. The hospital’s IT would be able to directly push health data to the district reporting system. Software developers around the globe could design add-ons and improvements to the technology that would facilitate regional preferences and government requirements. Global digital health and mHealth technologies have the possibility to greatly improve health and wellbeing. In order to reach this potential, it is critical to move towards standardization and interoperability.
