The COVID-19 pandemic has highlighted the vast inequities in global health. Countries are being forced to reimagine the delivery of health care services. They are investing heavily in digital technologies[1] to build resilient health care systems. Global investments in digital health in 2020 increased by 103% compared to the previous year (from $10.6 billion in 2019 to $21.6 billion in 2020)[2].
However, deciding which digital solutions to invest in sustainably is a complex problem. With limited resources and the need to address a multitude of health systems challenges[3], countries still need to:
Poor investment choices in fragmented software systems can accumulate technical debt[7], costing countries millions of dollars of recurrent costs.
Challenges in deploying sustainable guideline-adherent digital health solutions
In countries, technology partners work with governments to develop digital solutions that meet health systems’ needs and benefit local populations. However, significant challenges remain in ensuring digital health interventions: contain health and data content consistent with government policies[8]; add value to the overall national digital ecosystem; and be easily implemented, maintained, and updated within the country’s budget.
For many business analysts and software developers, the resource burden of, interpreting national and WHO’s evidence-based data and clinical recommendations, preparing well-documented requirements, adopting appropriate interoperability standards, and building well-architected digital systems, have led to accumulating non-standards-based monolithic legacy digital systems and considerable technical debt in countries.
In all digital health service delivery and reporting systems, consistency with evidence-based health and data content, and conformance to interoperability standards is critical. HL7 FHIR (Health Level Seven Fast Healthcare Interoperability Resources) is an open data exchange standard that supports interoperability across patient-centered healthcare applications. ICD-11 (International Classification of Diseases) provides the terms to ensure consistency in data representation; and CQL (clinical quality language) provides consistency in calculating decision-support and indicators. These free and open standards are emerging as necessary elements to drive the person-centered digital transformation of health systems. They will serve as the foundation of WHO’s SMART guideline approaches for digitalizing WHO guidelines recommendations as part of the Global Digital Health Strategy. These standards are further leveraged to develop a supporting ecosystem of software libraries, services, and tools – as digital public goods – for countries and their partners.
At the beginning of the SMART Guidelines work, robust software libraries were not available to natively read and execute FHIR and CQL content on software used in resource constrained environments, so WHO focused on two initiatives:
Facilitating the development of code libraries
As a considerable proportion of digital health interventions in low-resource contexts are delivered offline on Android devices, these devices must be able to execute interoperability standards directly (natively) on the device. They must also be able to interoperate within national data exchange enterprise environments. To ensure such software would be available, WHO convened various stakeholders to define technology gaps and guide common requirements for code libraries that would facilitate the native execution of CQL and FHIR. Led by Google, and supported by a number of digital health technology partners, these common requirements became the basis of technical work, to develop an open-source Android FHIR Software Development Kit (SDK).
The SDK enables local software developers to build upon the standard-based components for country-specific, offline-capable, and interoperable applications. The components offered by the SDK includes local storage, data access, search, sync Application Programming Interfaces (APIs), and a partial implementation of the HL7 FHIR Structured Data Capture (SDC) specifications for rendering HL7 FHIR Questionnaires into data collection tools.
Translating WHO recommendations into machine-readable, open digital health standards
The SMART Guidelines approach is a dynamic way of repackaging existing, evidence-based guidance to inform countries' investment in digital systems. WHO SMART Guidelines comprise of documentation and digital health components that can guide localization and implementation of evidence-based recommendations through digital systems. This approach enables: guideline developers to translate recommendations into technical specifications and standards; technologists to integrate recommendations into dynamic digital systems; and countries to create interoperable and institutionalized digital systems that are up-to-date and consistent with evidence-based recommendations.
WHO is using the SDK to facilitate the development of software solutions supporting SMART Guidelines, for frontline workers. Examples include EmCare, which is focused on child health in emergencies; and software solutions that support adoption of Digital Documentation of COVID-19 Certificates (DDCC) guidance.
Digital transformation of health systems
With a supporting ecosystem of tools, including the SDK, SMART Guidelines can bring rapid digital transformation of health systems. By supporting Ministries of Health, their implementing partners, and health workers to adopt standards-based mobile technologies and integrated decision support tools, the SDK and SMART Guidelines can systematize and accelerate the consistent application of life-saving interventions globally.
As countries are increasingly investing in their digital transformation, they are focused on ensuring their approaches serve as a foundation that can evolve with their diverse short- and long-term needs. For countries and their technology partners to succeed, an intentional focus on digital health enterprise architecture, adopting interoperability standards, consistent use of robust and extensible code, and coordinated investment by diverse stakeholders toward applications and services delivering digital benefits across the entire digital health enterprise must exist.
How to Participate
WHO is inviting interested parties to join weekly working group calls focused on building the SMART digital ecosystem, including evolving or implementing the SDK. If you're interested in participating in the working group calls or learning more, please contact [email protected].
[1] https://www.nature.com/articles/s41746-021-00487-4
[2] https://mercomcapital.com/product/q4-and-annual-2020-digital-health-healthcare-it-funding-and-ma-report/
[3] Classification of digital health interventions v1.0
[4] Digital Implementation Investment Guide (DIIG): Integrating Digital Interventions into Health Programmes
[5] https://www.nature.com/articles/s41746-019-0158-1
[6] https://wiki.digitalsquare.io/index.php/Navigator_for_Digital_Health_Capability_Models
[7] https://www.mckinsey.com/business-functions/mckinsey-digital/our-insights/tech-debt-reclaiming-tech-equity
[8] https://journals.sagepub.com/doi/full/10.1177/1460458219876183