Electronic health, telemedicine, and new paradigms for training and care

Abstract

Purpose of review 

HIV prevention and care is changing rapidly; guideline revisions and programmatic scale-up require innovative approaches to in-service training and care extension to improve provider practice and care access. We assessed recent (≤12 months) peer-reviewed publications on electronic health (eHealth), telemedicine, and other innovative provider-targeted interventions for HIV-related care.

Recent findings 

Key developments included systems merging electronic medical records (EMR) with provider clinical decision aids to prompt action, demonstration eHealth, and telemedicine projects, reviews or descriptions of technology to improve connectivity in lower resource settings, and a few trials on provider-centered interventions. Most publications were program reports and few data were available regarding efficacy of eHealth interventions for providers on patient HIV-related outcomes, notably identification and management of antiretroviral treatment failure in Kenya. Better evidence is needed for strategies to train providers and care extenders with the goal to improve impact of HIV prevention and care interventions.

Summary 

Rapid technology introduction and expansion may change the paradigm for improving provider knowledge and practice. Although new, the developments are promising for HIV provider-targeted eHealth and innovations for traditional training. More rigorous testing with randomized trials is needed to demonstrate impact on services for people living with HIV.

INTRODUCTION

Continuing education and support for providers is critical in light of periodic changes in guidelines for HIV care and treatment, coupled with mandates for rapid scale-up of care ^[1,2]. This is particularly true in remote areas and for primary care cadres without infectious disease or HIV subspecialty training. Traditional in-service training, such as centralized workshops with ongoing support, may not be feasible in some settings; in addition, expert input may be needed urgently at times, and case acuity or other access challenges obviate the ability to refer for specialist care. These variables highlight the need for an effective strategy to build providers’ capacity.

Electronic health (eHealth), defined by the WHO as the use of information and communication technologies (ICT) for health ^[3], offers novel approaches to provider training, records-based clinical guidance, and proxy actions to extend care for people living with HIV (PLHIV). eHealth comprises several domains, including mobile health (mHealth), health information systems/electronic medical records (EMR), telemedicine, and eLearning, and the various formats have been utilized across different health areas in recent years. We aimed to review and synthesize recent eHealth (with particular focus on telemedicine) and other approaches to provider training and client care improvement for HIV with a critical analysis of gaps in the literature and recommendations for potential next steps.

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REVIEW APPROACH AND PROCESS

The current review was based on search of peer-reviewed literature published between 1 April 2016 and 13 April 2017, conducted on 14 April 2017. PubMed, Global Health, Academic Search Premier, and Cochrane databases were searched using the terms: (eHealth OR telemedicine OR mobile phone* OR cell phone* OR SMS OR mhealth OR mobile health* OR m-health OR electronic health* OR ehealth OR e-health OR text messag* OR mobile messag* OR smart phone* OR smartphone* OR social media* OR mobile technolog* OR computers, handheld) AND (training OR education OR teaching OR delivery of healthcare) AND (HIV OR HIV infections), producing 207 unique references. Of these, 65 full text articles were assessed by one author (C.S.T.), with 29 included in this review. Inclusion criteria were based on content including eHealth, telemedicine, or innovative provider training or support interventions for HIV care, including ICT or other technology descriptions relevant to provider-targeted interventions.

HUMAN RESOURCE INTERVENTIONS FOR HIV CARE & RELEVANCE OF ELECTRONIC HEALTH

In considering education and support for HIV care providers, we extended our review scope to include: traditional in-service training for health professionals without eHealth modalities; training of alternate HIV care providers, a broad cadre of health workers in less resourced settings who often complement or substitute for certified professionals; and non-eHealth approaches to extend reach of services (Table 1). Our rationale for including these publications is to lay a foundation for available and potentially successful care models to which eHealth technologies may be applied to streamline or further extend care. Ultimately, the performance of health providers will depend on quality improvement methods, coaching, mentoring, and supportive supervision that maximize impact. Vasan et al.^[7▪▪] summarized evidence for these methods on the performance of healthcare workers in primary healthcare settings in a systematic review. The authors found that many (57.5%) studies addressed ‘supportive supervision’ and found generally positive results, with seven of the 40 reviewed studies being randomized controlled trials (RCTs). Despite this volume and rigor, they noted little clarity about the most effective features of supervision, as well as the design, implementation, and monitoring of supervision programs. The same was true for the other dimensions of interventions for improved healthcare worker performance, for example, mentoring, coaching, and quality improvement. Next steps should include reaching a consensus on a systematic definition of supportive supervision and mentoring, to be followed by establishing standards specific to HIV care for each of these activities.

Table 1: Description of peer-reviewed articles containing alternate provider training approaches for HIV and related care published between April, 2016 and April, 2017 (n = 8)

Specific interventions focusing on training for health professionals found positive impact on HIV patient care for stigma and rights-based care and influenza guideline training,^[4,5] and, within a review assessing approaches to improve prevention of mother to child transmission, on maternal antiretroviral treatment (ART) use ^[10].

Alternate HIV care providers, cadres typically serving as community outreach workers, peer navigators, or frontline primary healthcare providers, may be able to reach clients who would otherwise be left without HIV care and treatment and, most importantly, make services more cost-efficient and client-friendly. As part of building evidence on task shifting to lower-level and lay providers and associated positive benefits, Ma et al.'s ^[11▪] systematic qualitative review found that task shifting reduces the shortage of medical professionals in lower and middle-income countries, improves the psychosocial well being of PLHIV, and strengthens the relationships between PLHIV and health providers by building trust. With implications for the training and capacity building of providers, the authors present evidence that essential knowledge and problem-solving skills were more useful than disease-specific treatment literacy in training for lay health workers. However, the best strategy has not yet been identified to effectively build capacity in and sustain the quality of these alternate providers. A targeted nutrition training intervention for frontline providers was found to have some improved weight gain among pediatric HIV patients with wasting as compared with control clinics in a cluster-randomized trial but follow-up was too brief to determine impact on stunting ^[6].

Last, interventions using novel approaches to HIV care provision with human resources were included. A program report with a two-phase intervention of training traditional birth attendants and other community-based cadres for counseling and providing mobile care units with both health professionals and frontline providers in India reported considerable patient reach but had no comparator group ^[9]. Bassett et al.'s ^[8▪] RCT is, as stated by the authors, the first published study to evaluate the effectiveness of patient care ‘navigators’ to optimize treatment for HIV and tuberculosis (TB). Even with this study's robust methodology and outcome measures to evaluate the efficacy of the navigator intervention for combined HIV and TB treatment, the authors found no difference in treatment outcomes between the intervention and standard care group. Although the authors note that intervention intensity – in this case, the performance of the navigators – was perhaps insufficient to improve outcomes, the study demonstrates the value of a rigorous evaluation design to indicate an intervention's effectiveness, weaknesses, and potential modifications for improvement.

ELECTRONIC HEALTH INTERVENTIONS

eHealth can encompass a variety of technological approaches, and 13 articles were included within this group (Table 2). Articles in this section were diverse, ranging from design or results of trials studying provider-centered interventions, project development and pilot studies, reviews of eHealth interventions partially or exclusively focusing on HIV, and evaluations of enhanced EMR or human resources information systems (HRIS) that included components to facilitate delivery of HIV care by providers. A single cluster-randomized intervention trial assessed the efficacy of an EMR enhanced with an embedded clinical decision support system on HIV treatment failure outcomes ^[16▪▪]. In that study, intervention facility providers received alerts via EMR for two types of notifications: when patients had a critical CD4 value or missed lab and to suggest clinical actions in response to lab results and recorded medications. Control facility providers only received a standard monthly patient report. Patients with immunologic treatment failure at intervention facilities were three times more likely to have treatment changed and had significantly shorter times from alert to action and from ART initiation to first laboratory monitoring. The evidence was high quality with analyses adjusted for potential confounding of differences in baseline disease stage at entry, and the results suggest that EMR systems to prompt provider action should be considered for scale-up. These systems are increasingly present in public-sector facilities and their functionality becomes more robust over time. However, the inability to eliminate article-based records as the initiating step and need for data clerks with the associated staffing and training burden should be improved in future iterations of EMR-based interventions. Three articles also provide insight into potential for merging provider-targeted interventions with EMR. Kang’a et al.^[14▪] reviewed EMR platforms in Kenya against national standards in 2012 and found that few of the evaluated EMR systems incorporated any integrated clinical decision-making aids. Two other program reports describe EMR and HRIS systems that incorporate provider-targeted components to improve care ^[18,19▪]; these systems work to integrate different databases to ensure comprehensive data are available to providers. Rettler et al.^[18] describe software that merges clinical site EMRs with the public health department's system to ensure HIV patients are retained within the cascade through notifications to field epidemiology personnel. Waters et al.^[19▪] report on an innovative system in Mozambique that merges data on provider skill sets, determined by in-service training and certification, and clinical sites needing personnel with those skills in areas the providers prefer, increasing likelihood of provider retention. However, efficacy data using patient outcomes and provider knowledge and satisfaction measures are needed before these demonstration models can be recommended at larger scale.

Table 2: Description of peer-reviewed articles containing information on electronic health interventions for HIV and related care providers published between April, 2016 and April, 2017 (n = 13)

Table 2: (Continued) Description of peer-reviewed articles containing information on electronic health interventions for HIV and related care providers published between April, 2016 and April, 2017 (n = 13)

Table 2: (Continued) Description of peer-reviewed articles containing information on electronic health interventions for HIV and related care providers published between April, 2016 and April, 2017 (n = 13)

Mobile-platform-based interventions are described in several articles and address a variety of HIV care areas, but efficacy data are lacking or data suggest no intervention impact ^[13,23]. A Kenyan review called for greater evaluation of mobile-based interventions generally; two recent systematic reviews found few HIV eHealth interventions targeting providers overall ^[22▪,23], and it is hoped that planned interventions will incorporate rigorous evaluation into design ^[12]. Internet-based interventions comprise models that act as provider proxies in a high-resource setting ^[20,21] or more directly supply information to health providers ^{[15▪,17▪]}. These interventions all assume a certain knowledge of and access to electronic media and, while smartphone use is expanding, interventions of this type may not be feasible for providers in some settings. Social media or an Internet platform to extend sensitization or care activities are promising in a high-resource setting and would benefit from efficacy data specifically for HIV care, patient input on user friendliness and confidentiality, and care outcomes ^[20,21]. Confidence in quality and reliability of information was also relevant to program assessments for provider learning where Wikipedia (Wikipedia.org), an open database with no internal validation, was provided as a potential electronic resource for health information with mixed reviews. From that study, rural providers identified the need for accessible, curated content specific to national guidelines and information to be made available in urgent situations ^[17▪]. An innovative approach to controlled content to supplement eHealth initiatives was also presented, linking program-generated video of scripted patient encounters through YouTube (LLC, San Bruno, California, US) ^[15▪]. This model holds promise and should be considered for augmentation of in-service training and support; formative studies are in process to determine best host sites (e.g., YouTube, WhatsApp Inc, Mountain View, California, US, Skype; Communications SARL, Luxembourg) in areas with variable connectivity, and cost-effectiveness in settings where smartphone use and connectivity are expanding. Larger sample sizes and rigorous trial design will be required to measure efficacy.

TELEMEDICINE INTERVENTIONS

Telemedicine interventions (Table 3) were more homogeneous than those identified for eHealth. Primary programs/studies included evaluation of four provider-focused telemedicine interventions,^{[26▪▪,27▪,28▪,29▪▪]} and two telephone-based care extension interventions in which providers called HIV patients with depression for consultation and symptom monitoring ^[25▪,30]. We also included a review ^[32▪] and a technology and study protocol description ^[31▪▪] that featured technology relevant to telemedicine intervention design and programming considerations.

Table 3: Description of peer-reviewed articles containing information on telemedicine for HIV and related care providers published between April, 2016 and April, 2017 (n = 8)

Table 3: (Continued) Description of peer-reviewed articles containing information on telemedicine for HIV and related care providers published between April, 2016 and April, 2017 (n = 8)

The Extension for Community Healthcare Outcomes (ECHO) model offers rural providers access to a multidisciplinary care team at an academic center and to other rural providers to create a community of practice with weekly online sessions. This program was evaluated by two separate implementing groups,^{[26▪▪,29▪▪]} with differing experiences between the two. The Washington group had providers joining from four other states; these providers rated the program highly and may have self-selected due to their and their patient populations’ greater isolation from HIV specialty referral sites as compared with the population in the second study ^{[26▪▪,29▪▪]}. The second study described ECHO super-imposed on the Veterans Administration system in the United States, in which referrals are possible but often require long-distance travel that is inconvenient for PLHIV in rural areas ^[26▪▪]. Moeckli et al.^[26▪▪] considered this factor, noting that specialty providers were often reluctant to relinquish care and believed PLHIV preferred to stay with providers with whom they had already developed rapport, whereas primary care providers felt more comfortable referring care to established specialist teams. The publications eligible for review inclusion for the two US projects did not analyze key patient outcomes, such as viral suppression or annual viral load monitoring, so we cannot comment on program efficacy at the patient level.

In Malawi and Botswana ^{[27▪,28▪]}, two studies describe systems analogous to ECHO that worked effectively in settings in which referrals are not possible or feasible. One potential weakness in a low-resource setting, however, is the reliability of Internet connection for meetings with a team of experts. In a tertiary facility in the national capital of Malawi, a pathology telemedicine intervention resulted in successful pathology team consultations, achieving high concordance in cytologic and histologic diagnosis. But Montgomery et al. did not comment on connectivity issues and their potential impact on consultative meetings ^[27▪]. A study in Botswana used a smartphone-based consultation service for dental cases, which may be a better paradigm as providers used smartphones to send data and photos to experts in the capital, Gaborone. However, more data are needed on differences between expert management recommendations and course of care, particularly on biopsy access and follow-through ^[28▪]. This smartphone model may be more practical due to popularity and widespread use of applications like WhatsApp that allow low-cost text/file transmission and calls through subscriber Internet coverage while avoiding mobile network charges. As Internet coverage and smartphone ownership increase in low resource settings, this approach may gain traction. In Botswana, another solution is being explored that may resolve connectivity issues by using underutilized television bandwidth. Chavez et al.^[31▪▪] describe plans to extend the current national telemedicine model to this ‘white space’ band and assess whether connectivity and expansion of expert clinical guidance across primary care fields make a measurable impact on provider access, knowledge, and quality of care. We recommend that the team also evaluate how specialists manage competing demands for guidance in urgent situations with their usual work and whether compensation becomes an issue. Other countries may wish to implement this model and, in doing so, may grapple with human resource issues on how to convene a consistently available expert panel.

CONCLUSION

The current review of recent publications on HIV service provider training and performance enhancement evaluates mobile technology, telemedicine, and other innovative provider-targeted interventions utilizing eHealth for HIV-related care. Review articles and service assessments illustrated functionality of mobile phone and EMR platforms and highlighted best features to make the technology more robust for provider-targeted applications. Similarly, reviews on interventions to improve provider performance, both specific to HIV and for primary care generally, identified successes as well as the need for greater standardization of models for provider support, particularly following in-service training with supportive supervision and mentoring. New applications of technology show potential, including using YouTube to broadcast scripted educational videos, sending clinical case information through smartphones and mobile apps, and using ‘white space’ frequencies to improve connectivity and access to content. Despite the promise of these interventions, firm evidence is needed to determine how feasible eHealth programming is in low resource and rural settings where connectivity remains limited, serving as a key limitation among many of the articles reviewed. Approaches to maintaining patient confidentiality, particularly in telemedicine and EMR-based systems, were explicitly considered by some but not all of the interventions described in this review. Going forward, patient confidentiality protections within the program are a necessary component that should be given the same weight as ethical review board approval for formal evaluations and standard minimum protection guidelines developed for nascent eHealth projects. Evaluations of feasibility and efficacy must be done rigorously to optimize the power of technology for telemedicine and preservice/in-service training and to ensure success at scale-up. Given the rapid pace of technologic development and expansion of both Internet coverage and HIV prevention and treatment modalities, we anticipate substantive change over the next few years in provider training and service extension to meet the needs of clients living with HIV.

Acknowledgements

We would like to thank Carol Manion, Allison Burns, and Tamara Fasnacht for their assistance with the literature searches.

Financial support and sponsorship

The current work was supported by the United States Agency for International Development (USAID) through Cooperative Agreement OAA-A-14-0045 to FHI 360 for the management and implementation of the LINKAGES Project. Views expressed do not necessarily represent the views of USAID nor FHI360.

Conflicts of interest

There are no conflicts of interest.

REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as:

• ▪ of special interest
• ▪▪ of outstanding interest