eHealth, the “use of information and communication technologies (ICT) for health” [1], is an internationally accepted and promoted need. mHealth, “use of mobile technologies for public health”, [2] has grown to include broad medical and health use and is a component of eHealth that is growing rapidly in both the developed and developing worlds [3–5]. Another component is eRecord systems, which includes Electronic Medical Records (EMR), Electronic Health Records (EHR), and Personal Health Records (PHR). To function efficiently these eHealth components need to interact as seamlessly as possible.
To advance such seamless interaction, interoperability (“the ability for two or more systems or components to exchange information and use the information that has been exchanged [6]”) of mHealth and eRecord systems is urgently required. This is especially so in the developing world, where silos of data have arisen due to ad hoc, often donor driven, initiatives and uncoordinated development [7]. The failure of many implementations could, in part, be due to their lack of interoperability with other eHealth components [8]. Such interoperability can be achieved at various ‘levels’ (technical, syntactic, semantic, organisational and legal) [9–12]. The benefits of interoperable eHealth systems are availability of shared up-to-date information, improved quality of care, and cost savings, while the barriers include cost, security and privacy issues, information overload, and liability issues [12].
Like many developing countries, Botswana has identified eHealth as a means of improving healthcare provision and delivery [13]. The recently launched Botswana National eHealth Strategy recognises the need for eHealth interoperability, and states, “Interoperability will be supported by establishing an interoperability architecture/platform that simplifies the complexity of interfaces that will be built between different information systems by creating a mediation layer (Health Information Mediator)” [13]. It also identifies the need for “Establishing a standards and interoperability framework” as well as the need to “Establish a home-grown EHR for Botswana” [13]. However, given the rapid anticipated growth in use of mHealth solutions globally, a notable omission of the strategy is its failure to address mHealth and interoperability approach or framework for linking mHealth and eRecord systems.
Many developing countries offer public healthcare services across a decentralised network of health facilities. In Botswana these include 3 national referral hospitals, 15 district hospitals, 17 primary hospitals, 357 clinics, 346 health posts and 1,117 mobile clinics [13], which account for 98% of healthcare facilities in the country [13]. The health information system landscape in Botswana is characterised by a lack of interoperability within and between the public and private sector eHealth systems, duplication of effort across eRecord systems, manual data sharing, and reporting without standardised procedures, thus posing challenges to confidentiality and loss of patient information [13]. Additionally, medical practitioners have little experience of using eHealth for healthcare provision. Although not sustained, a number of mHealth initiatives have been implemented in Botswana to support priority health programmes through a coalition of public and private partners [14–21].
A recent review of eHealth interoperability frameworks found none to be entirely suitable nor adequate on their own to address linking of mHealth applications to eRecord systems in the context of the developing world and, more specifically, Botswana [22]. Identified limitations of the frameworks included assumptions of: 1) an adequate pre-existing ICT infrastructure (hardware and software), 2) a health sector architecture utilising established interoperability standards, 3) robust governance structures, 4) a healthcare sector with established eHealth services and human resource capacity to support eHealth systems, and 5) acceptance of ICT solutions by eHealth users including patients.
Another study, based on local eHealth experts’ opinion and a review of the National eHealth Strategy, described Botswana’s eHealth interoperability landscape and provided guidance on linking mHealth applications to existing eRecord systems [23]. Desirable interoperability features were identified for linking mHealth and eRecord systems, such as interoperability standards, application programming interfaces (APIs), data formats and security considerations. It was also found that the only mHealth implementation recognised by the Ministry of Health and Wellness (MoHW), the Kgonafalo mobile telemedicine programme, was not linked to any eRecord system. Kgonafalo was a store and forward mobile phone-based telemedicine programme supporting dermatology, cervical cancer, oral health, and radiology [14]. Interviewees identified four major themes requiring attention: 1) eHealth legislation and governance; 2) eHealth software and infrastructure; 3) data standards, security, and Unique Patient Identifier; and 4) capacity building [23].
Furthermore, the National eHealth Strategy review identified the open health information exchange (OpenHIE) framework and its reference tool, the Open Health Information Mediator (OpenHIM), as the preferred approach to support eHealth interoperability [22, 23]. OpenHIE offers an adaptable framework utilising standard-compliant architectural components [24]. The Strategy review further identified the adoption of global goods [25] (universally available software, services and content) as an appropriate approach.
Given the importance of linking mHealth solutions to eRecord systems in Botswana and the developing world, a suitable interoperability framework relevant to their needs is required. Such a framework would provide for an agreed approach to interoperability for organisations wishing to work together, and specify common elements [26, 27].
Building upon prior research findings, the aim of this study is to describe the design and development of a conceptual framework for linking mHealth solutions to eRecord systems. The resultant mHealth-eRecord Interoperability Framework (mHeRIF) is relevant to both Botswana and the developing world.