eHealth is defined by the World Health Organization (WHO) as “the use of Information and Communications Technologies (ICT) for health” [1] and comprises four application areas (health informatics, telehealth, e-learning, and e-commerce [2]). mHealth, a component of telehealth, is “the use of mobile communications for health information and services” [3], and mHealth applications (ways in which all modes of mHealth hardware, software, infrastructure, and connectivity can be used for specific purposes, not merely ‘apps’) are used extensively worldwide to address many health and healthcare needs [4].
Like mHealth, the use and implementation of electronic record (eRecord) systems such as electronic health records (EHR), electronic medical records (EMR) or patient health records (PHR) is growing rapidly. By 2017, 84% of hospitals, 93% of clinics and 96% of general practitioners in the European Union (EU) used an electronic patient record system [5], and in the United States 99% of hospitals [6] and 86% of office-based physicians had adopted an EHR [7]. The situation in the developing world is somewhat different. Fewer than 15% of low income countries have been reported to have a national EHR [8], although developing countries have implemented various programme or disease specific eRecord systems to augment current paper-based methods [9, 10].
Similarly, differences exist in regard to mHealth. Developed countries predominantly use smartphones and have implemented formal mobile solutions, whereas in developing countries basic phones and feature phones still predominate and, given the lack of or limited regulations, mHealth is used more informally [11]. Thus, whilst sub-Saharan Africa has been a focal point for many formal mHealth projects, informal use appears common. For example, in three sub-Sahara Africa countries, 15% of Community Health Workers surveyed used formal mHealth applications whilst over 97% regularly used a personal mobile phone informally for work-related purposes [11, 12]. Such trends are likely to be spurred by recent global awareness and application of eHealth, including mHealth, due to the COVID-19 pandemic [13].
The benefits of eRecord systems are well documented, particularly the prevention of duplicate tests and improved quality of care related to accessing patient information between different sites as and when required [14]. The primary benefit of mHealth is, as the name implies, mobility and the potential to use this to advantage in extending geographic access to healthcare in any location where there is connectivity. Linking of mHealth applications and eRecord systems should result in seamless data exchange within a healthcare community with subsequent benefit [15]. As early as 2006, it was estimated that the potential benefits of a fully implemented standardised health information exchange and interoperability (HIEI) system in New York State could have a net value of $4.54 billion annually, or about 3.3% of the State’s total 2003 healthcare expenditures [16].
Despite widespread adoption, interoperability of mHealth applications and eRecord systems remains a global challenge [14]. Interoperability is a broad and complex subject with numerous definitions. The Healthcare Information and Management Systems Society’s (HIMSS) definition is the most encompassing, “the ability of different information systems, devices and applications (‘systems’) to access, exchange, integrate and cooperatively use data in a coordinated manner, within and across organizational, regional and national boundaries, to provide timely and seamless portability of information and optimize the health of individuals and populations globally” [17] to which could be added a component “… without special effort on the part of the user”, from the definition of the Office of the National Coordinator for Health Information Technology [18].
In general, interoperability deals with using standards, interfaces, and protocols to connect systems and services, using appropriate software engineering techniques and methodologies, and all associated issues that may impact this process. These include legislation, agreements between exchanging parties, governance, shared workflows, standardised data elements, semantic and syntactic choices, applications, technical infrastructure, safety, time, geolocation, and privacy issues.
Interoperability can be achieved at various ‘levels’ (technical, syntactic, semantic, organisational and legal) [19, 20]. It can also be assessed in other ways. One approach is to use the FAIR guidelines to assess the capacity of computational systems to Find, Access, Interoperate, and Reuse (FAIR) data with minimal or no human intervention [21].
The implementation and adoption of eRecord systems and mHealth applications in sub-Saharan Africa has been slow and the systems that are in place have usually been developed by donors for a single problem, such as HIV/AIDS, tuberculosis, or malaria. This has resulted in silos of eRecord systems often containing similar data on the same patients, and extensive ‘donor-driven pilotitis’ [22]. In 2010, Uganda had over 50 concurrent mHealth and eHealth projects (and almost as many donors) and at least a dozen eRecord systems, stimulating the Government to issue on 17th January 2012, a moratorium. This directed that “all eHealth projects / initiatives be put to halt until” specified national and institutional infrastructure was established, e.g., District Health Information Systems version 2 (DHIS2) interoperability, and national eHealth policy and strategic frameworks were established [22]. A similar problem was highlighted in Botswana where, in 2013, the Ministry of Health and Wellness (MOHW) reduced 37 distinct eRecord systems to a more manageable nine [23].
Like many developing countries, Botswana has identified mHealth as a means of improving healthcare provision and delivery, especially in rural areas [9]. Past localised efforts have been made to use mHealth in four clinical areas [24], but none were linked to any eRecord system(s). In this paper, Botswana is used as an exemplar of the interoperability setting in developing world countries, and an approach to identifying and resolving mHealth and eRecord systems interoperability issues is described.
Provision of healthcare in Botswana is decentralised, with an extensive network of health facilities distributed throughout 27 health districts. This includes: 3 national referral hospitals, 15 district hospitals, 17 primary hospitals, 357 clinics, 346 health posts, and 1,117 mobile stops [23]. Like other developing world countries, Botswana has diverse eRecord systems from different vendors and donors within the public and private health sectors. Interoperability is often non-existent, a situation exacerbated by use of various proprietary eRecord systems and mHealth applications. This has led to fragmented care delivery, duplication of effort and unnecessary healthcare expenditure.
Whilst Botswana’s recent eHealth Strategy addresses the development of an interoperability platform, it provides no guidance regarding interoperability of mHealth applications and eRecord systems. This is consistent with a recent systematic review of mHealth interventions in developing countries which concluded that “most of the mobile health interventions are not ready for interoperability and to be integrated into the existing health information systems” [25]. In addition, despite the proliferation of both mHealth applications and eRecord systems, the need for their bi-directional interoperability has not been fully appreciated or addressed in Botswana [26]. This shortcoming must be addressed.
Using Botswana as the exemplar of a developing world country, the aim of this study was to engage with local eHealth experts about interoperability and linking mHealth applications to eRecord systems and conduct a review of the Botswana National eHealth Strategy. The goal was to inform and expand interoperability approaches available to developing countries and to facilitate enhancement of Botswana’s National eHealth Strategy in particular.