http://www.diva-portal.org

This is the published version of a paper published in Global Health Action.

Citation for the original published paper (version of record):

Wallis, L., Hasselberg, M., Barkman, C., Bogoch, I., Broomhead, S. et al. (2017)A roadmap for the implementation of mHealth innovations for image-based diagnosticsupport in clinical and public-health settings: a focus on front-line health workers andhealth-system organizations.Global Health Action, 10: 1340254https://doi.org/10.1080/16549716.2017.1340254

Access to the published version may require subscription.

N.B. When citing this work, cite the original published paper.

Permanent link to this version:http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-143548

Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=zgha20

Download by: [Umeå University Library] Date: 04 January 2018, At: 01:43

Global Health Action

ISSN: 1654-9716 (Print) 1654-9880 (Online) Journal homepage: http://www.tandfonline.com/loi/zgha20

A roadmap for the implementation of mHealthinnovations for image-based diagnostic supportin clinical and public-health settings: a focus onfront-line health workers and health-systemorganizations

Lee Wallis, Marie Hasselberg, Catharina Barkman, Isaac Bogoch, SeanBroomhead, Guy Dumont, Johann Groenewald, Johan Lundin, JohanNorell Bergendahl, Peter Nyasulu, Maud Olofsson, Lars Weinehall & LucieLaflamme

To cite this article: Lee Wallis, Marie Hasselberg, Catharina Barkman, Isaac Bogoch, SeanBroomhead, Guy Dumont, Johann Groenewald, Johan Lundin, Johan Norell Bergendahl,Peter Nyasulu, Maud Olofsson, Lars Weinehall & Lucie Laflamme (2017) A roadmap for theimplementation of mHealth innovations for image-based diagnostic support in clinical and public-health settings: a focus on front-line health workers and health-system organizations, Global HealthAction, 10:sup3, 1340254, DOI: 10.1080/16549716.2017.1340254

To link to this article: https://doi.org/10.1080/16549716.2017.1340254

© 2017 The Author(s). Published by InformaUK Limited, trading as Taylor & FrancisGroup.

Published online: 25 Aug 2017.

Submit your article to this journal Article views: 301

View related articles View Crossmark data

CAPACITY BUILDING ARTICLE

A roadmap for the implementation of mHealth innovations for image-baseddiagnostic support in clinical and public-health settings: a focus on front-linehealth workers and health-system organizationsLee Wallis a, Marie Hasselbergb,c, Catharina Barkmand, Isaac Bogoche, Sean Broomheadf,g, Guy Dumontc,h,i,Johann Groenewaldc, Johan Lundinb,j, Johan Norell Bergendahlk, Peter Nyasulu l,m, Maud Olofssonc,Lars Weinehalln and Lucie Laflammeb,c,o

aDivision of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Bellville, South Africa; bDepartmentof Public Health Sciences, Global Health, Karolinska Institutet, Stockholm, Sweden; cStellenbosch Institute for Advanced Study (STIAS),Wallenberg Research Centre at Stellenbosch University, Stellenbosch, South Africa; dStockholm County Council, Forum for Health Policy,Stockholm, Sweden; eDivisions of General Internal Medicine and Infectious Diseases, Department of Medicine, University of Toronto,Toronto, Canada; fAfrican Centre for eHealth Excellence, Cape Town, South Africa; gHealth information Systems Programme, Pretoria,South Africa; hDepartment of Electrical and Computer Engineering, University of British Columbia, Vancouver, Canada; iBritish ColumbiaChildren’s Hospital Research Institute, Vancouver, Canada; jInstitute for Molecular Medicine Finland – FIMM, University of Helsinki,Helsinki, Finland; kJumpahead AB, Stockholm, Sweden; lDepartment of Public Health, School of Health Sciences, Monash University,Johannesburg, South Africa; mDivision of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, Universityof the Witwatersrand, Johannesburg, South Africa; nEpidemiology and Global Health, Department of Public Health and ClinicalMedicine, Umeå University, Umeå, Sweden; oInstitute for Social and Health Sciences, University of South Africa, Johannesburg, South Africa

ABSTRACTBackground: Diagnostic support for clinicians is a domain of application of mHealth tech-nologies with a slow uptake despite promising opportunities, such as image-based clinicalsupport. The absence of a roadmap for the adoption and implementation of these types ofapplications is a further obstacle.Objectives: This article provides the groundwork for a roadmap to implement image-basedsupport for clinicians, focusing on how to overcome potential barriers affecting front-lineusers, the health-care organization and the technical system.Methods: A consensual approach was used during a two-day roundtable meeting gatheringa convenience sample of stakeholders (n = 50) from clinical, research, policymaking andbusiness fields and from different countries. A series of sessions was held including smallgroup discussions followed by reports to the plenary. Session moderators synthesized thereports in a number of theme-specific strategies that were presented to the participants againat the end of the meeting for them to determine their individual priority.Results: There were four to seven strategies derived from the thematic sessions. Oncereviewed and prioritized by the participants some received greater priorities than others. Asan example, of the seven strategies related to the front-line users, three received greaterpriority: the need for any system to significantly add value to the users; the usability ofmHealth apps; and the goodness-of-fit into the work flow. Further, three aspects cut acrossthe themes: ease of integration of the mHealth applications; solid ICT infrastructure andsupport network; and interoperability.Conclusions: Research and development in image-based diagnostic pave the way to makinghealth care more accessible and more equitable. The successful implementation of thosesolutions will necessitate a seamless introduction into routines, adequate technical supportand significant added value.

ARTICLE HISTORYReceived 1 April 2017Accepted 6 June 2017

RESPONSIBLE EDITORNawi Ng, Umeå University,Sweden

SPECIAL ISSUEmHealth for Improved Accessand Equity in Health Care

KEYWORDSmHealth; telemedicine;image-based; disgnositicsupport; roadmap

Background

mHealth technologies have transformed the world ofmedicine and the delivery of health-care services irre-versibly and, in some instances, at a remarkably rapidpace. The field has grown so much and so quickly thatit is difficult to summarize it without offering different,and often overlapping, classification alternatives.Classification can be based on the target of deliveryof an app, the place where the service is aimed to beapplied – in relation to the health sector as well as

geographically – or the health outcome(s) that it tar-gets (see Figure 1). The emphasis of this article is onmHealth applications for diagnostic and treatmentassistance among health-care providers, regardless ofthe health outcome, and with a particular focus onimage-based applications. This interest stems fromthe poor uptake of the technology [1] despite thesignificant gains in time, resources and quality ofcare that such applications could offer by remedyingone of the most challenging barriers to health-care

CONTACT L. Wallis leew@sun.ac.za; admin@afem.info Division of Emergency Medicine, Faculty of Medicine and Health Sciences, StellenboschUniversity, Private Bag X24, Bellville 7535, South Africa

GLOBAL HEALTH ACTION, 2017VOL. 10, 1340254https://doi.org/10.1080/16549716.2017.1340254

© 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permitsunrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Dow

nloa

ded

by [

Um

eå U

nive

rsity

Lib

rary

] at

01:

43 0

4 Ja

nuar

y 20

18

delivery in resource-scarce settings, i.e. that of accessto (or outreach of) expert advice.

Themost enthusiastic will claim that, in a foreseeablefuture, rapid developments in InformationCommunications Technologies (ICTs) and wirelessInternet systems will jointly provide for the conceptionof a variety of low-cost and clinically reliable andpowerful image- based apps supplying crucial health-care information, between individual clinicians or, withthe developments in machine learning, in an automatedfashion. In this scenario, front-line clinicians andhealth-care professionals will be able to receive real-time assistance for diagnosing a range of clinical condi-tions, and they will be provided with advice on how bestto manage each situation, including treatment andreferral advice. The less enthusiastic may claim thatbuy-in among clinicians will be poor, as it has beenamong patients (or laypeople) in the case of applica-tions targeting health behaviours, with pilot projectsbeing launched but never properly implemented andsustained. Will there be an interest for such powerfulmHealth clinical tools? And will front-line practitionerstrust and implement them in their routine practice? Ifso, under which conditions?

The method by which mHealth and other digitalinterventions should be implemented in clinical andhealth-care settings is unclear, with additional chal-lenges when implementation is targeted for resource-scarce settings. The field needs a roadmap for innova-tions to be adopted and implemented as there are manyfoci for application, be it general [2], targeting particularsegments of the population [3,4] or disease-specific [5].While there are several clinical, technological andhuman aspects that such a roadmap should incorporate(e.g. Figure 2 ‘’), this article covers three of the six keycomponents, aiming to answer the following question:What mechanisms are likely to help overcome the mostimportant barriers to the implementation of mHealthfor image-based diagnostic assistance in the clinicalsetting considering in turn front-line health workers

(as a target group of clinical users), health-care organi-zation and the technology (or technical environment)?

Methods

Procedure – a roundtable event

The investigation was embedded in a two-day round-table meeting that gathered a mix of participantsfrom different sectors of activities and different coun-tries (see later in this article), in the tradition of theStellenbosch Institute for Advanced Study (STIAS)[6]. The philosophy of the roundtables holds thatconsultation with interested and affected parties isan important pillar of success in many researchdomains. Roundtables are meant to stimulate thecross-pollination of ideas by providing a forum fordiscussion amongst researchers, practitioners, public-and private-sector leaders, civil-society and potentialbeneficiaries of research and its application orimplementation.

In this roundtable, which took place in February2017, we focused on one domain of application ofmHealth, which is image-based diagnostic and treat-ment assistance among clinicians. The theme of themeeting was ‘Implementing image-based mobiletechnology for diagnostic and treatment to improveaccess and equity in health care’. The organizingcommittee consisted of a mixture of people fromSweden and South Africa, representing differentfields of interest and competences. The ambition ofthe committee was to create the best possible condi-tions to draw the main line of a road map for theimplementation of those mHealth solutions. Themain principles followed while preparing the round-table (a period of about one year) were:

● Draw from knowledge from studies on andapplications of mHealth interventions from adiversity of domains but pay attention to their

Figure 1. Categorization of the field of mHealth according todomain of application, place of use and medical field wheremHealth is currently being applied.

Figure 2. Components of a roadmap to the implementationof image-based mHealth solutions.

GLOBAL HEALTH ACTION 59

Dow

nloa

ded

by [

Um

eå U

nive

rsity

Lib

rary

] at

01:

43 0

4 Ja

nuar

y 20

18

relevance for mHealth for image-based diagno-sis in clinical settings

● Focus on solutions rather than problems (e.g. whatto do and how to do it) for successful solutions

● Start with a general session on implementationissues and then subsequently focus remaining ses-sions around targeted issues for mHealth roadmaps– i.e. end users, workplace organization, technology

● Inform the discussions through short presenta-tions from experts and specialists representingdifferent stakeholders and broad perspectives

● Permit everyone ample opportunities to expresstheir views through several modalities such as ininteractive small group sessions, in a specificplenary and in speaker corners

Participants

Those who participated in the roundtable were a con-venience sample of people from several sectors of activ-ity, in line with the STIAS tradition of such events. Allparticipants took part in the event on a voluntary basis.The organizing committee was composed of stake-holders from Sweden and South Africa, who togetheridentified a list of potential participants based on gov-ernmental agencies, public and private organizations ofinterest, health-app developers and individual research-ers. All of them were contacted by STIAS by email,using a standardized invitation letter. On some occa-sions those persons contacted recommended otherpotential participants. In a few instances, individualswho had heard about the upcoming event asked theorganizers for participation. For the STIAS events, ide-ally, the number of participants is expected to be some-where between 40 to 50 with a balance amongresearchers, practitioners (in our case clinicians), pol-icymakers and people from the business sector. For thisroundtable, a new element was the inclusion of a num-ber of doctoral and medical students involved inresearch projects on mHealth in the Western Cape(South Africa). As for previous roundtables, policy-makers and business representatives were difficult torecruit and they are under-represented among the par-ticipants (see Table 1). The researchers and cliniciansrepresented a range of disciplines and competencesincludingmedicine, nursing, engineering, public health,psychology and economics.

There are also usually more participants fromSouth Africa and Sweden than from any other coun-try or group of countries as those events are orga-nized by representatives from Sweden and SouthAfrica. Other African countries represented at themeeting were Uganda, Tanzania, Kenya, Malawi andMali. From among the 55 confirmed participants, 50actually attended the first day (36% women). It is ofnote that a few people heard about this upcomingevent and asked to take part in it, which the organiz-ing committee approved.

Data-collection procedure

To determine what should be considered and whatshould receive priority under each overarching area,we proceeded as follows; the event itself was dividedinto thematic sessions of about 1.5 hours. Four ofthese sessions covered one aspect of the road mapand highlighted the following questions.

● How should the most important barriers to theimplementation of image-based mHealth in theclinical setting be overcome?

● How can front-line health-care workers be enabledto adopt image-based mHealth in their practice?

● Which are the key strategies to overcome orga-nizational challenges to the implementation ofimage-based mHealth within the health sector?

● Which are the key strategies to overcome tech-nical challenges in implementing image-basedmHealth within the health sector?

Figure 3 summarizes the steps taken to create the listof statements to be considered for priority setting.Within each session, four speakers presented one aspectrelevant to the theme covered, based on the domain ofexpertise that he or she represented and building onfacts, findings from ongoing research and reviews offindings. Directly after the presentations, the partici-pants turned to their small-group sessions and dis-cussed the question presented to them for 30 minutes.Each group had a chair and a rapporteur, and eachdiscussion was assigned a note-taker on a rotationalbasis; all roles were assigned in advance by the organiz-ing committee. One at a time, the rapporteurs fromeach table summarized what was felt to be the most

Table 1. Distribution of the participants to the roundtable by sector of activity and country.Country

Sector RSA Africa: Other Sweden Europe: Other North and Central America

Clinical 2 5Clinical research 1 1 1Research 7 1 8 4 1Policy 4 3Business 4 1 1Doctoral students 3Medical students 2 1

60 L. WALLIS ET AL.

Dow

nloa

ded

by [

Um

eå U

nive

rsity

Lib

rary

] at

01:

43 0

4 Ja

nuar

y 20

18

relevant action items and main points. The order of thegroup reports changed in all sessions.

Each session was chaired by two moderators (twonew ones for each session) and had two secretaries.The secretaries took notes during the rapporteurs’presentations, and gathered the notes taken fromeach of the note takers during the group work.Moderators and the secretaries then met to formulatethe strategies that best represented what had beenexpressed verbally and in writing. This involved high-lighting key issues, actions and main points withoutlosing key information. There were five to sevenstrategies elaborated in each session.

The strategies of each session were then printed onindividual and large sheets of paper (A3 format) and

placed under their respective questions on one side of alarge white board (1.5 m x 1.2 m). We used four whiteboards – each stating one of the key questions and itsrelated strategies. This was done in duplicate to enableparticipants to circulate around the room and to reduceany potential peer pressure when voting for a particularstatement. When the voting session started, each parti-cipant received an envelope with 12 Post-it markers infour different colours: three markers for each session.The participants were instructed to use their markers(votes) on the strategies that they considered were mostimportant in their own view (and context). At thatmoment, there were a total of 41 participants in theroom. It took about 20–25 minutes for all participantsto complete their votes (see Figures 4 and 5).

Figure 3. Procedure for data collection and priority setting by theme (session).

Figure 4. Illustration of the session where the participants proceeded to vote on the strategies they thought should receivepriority, one theme at a time. The question related to each theme is at the top of the white board and the strategies proposedunderneath the question. [Photo: Lisa Blom].

GLOBAL HEALTH ACTION 61

Dow

nloa

ded

by [

Um

eå U

nive

rsity

Lib

rary

] at

01:

43 0

4 Ja

nuar

y 20

18

Results

Overcoming the most important barriers

Table 2 presents the six strategies derived from thesession concerning how to overcome the most impor-tant barriers to the implementation of mHeath in gen-eral terms, and voting results from that session. Thestrategy that received the highest proportion of votes(33.6%) – i.e. the one that the participants would prior-itize most – relates to the ease of the integration of thenovel technology into local infrastructure. It is followedby three other strategies (each receiving roughly 20% ofvotes) on policy regulation/deregulation, continuous

quality improvement, and the quality of the conditionsfor implementation.

Overcoming barriers among front-line health-care workers

The strategies formulated during the session concern-ing factors that may enable front-line health workersto overcome barriers in mHealth implementation arepresented in Table 3. Although five strategies werehighlighted as a result of the plenary session, threestood out – in particular the need for any system tosignificantly and immediately add value to the users

Figure 5. Illustration of the session where the participants proceeded to vote on the strategies they thought should receivepriority, one theme at a time. The question related to each theme is at the top of the white board and the strategies proposedunderneath the question. [Photo: Lisa Blom].

Table 2. How should the most important barriers to the implementation of image-based mHealth consultation in the clinicalsetting be overcome? (n = 122 votes).

Strategy

Votes

n %

Ensuring the novel technology can be integrated into local infrastructures for routine use (e.g. ensuring there is the appropriate electricalpower, network connectivity and availability of devices).

41 33.6

Addressing policy deregulation and ‘light-touched regulations’ to implementation and scale of innovative technology. 25 20.5Continuous quality improvement initiatives to ensure the highest practice standards are maintained over time, and mechanisms to ensurethat the mHealth innovations meet (and preferably exceed) acceptable standards of care.

24 19.7

Ensuring the most suitable environment for the introduction, scale and maintenance of devices through multi-sectoral stakeholderengagement (government; clinical health care, public health, end-users; business and business models).

21 17.2

Implementation of education strategies for all users (e.g. among health care, the general public, government). 8 6.6Ensuring that the novel technological tools meet the requisite ‘gold standard’ for implementation. 3 2.5

Table 3. How can front-line health-care workers be enabled to adopt image-based mHealth in their practice? (n = 121 votes).

Strategy

Votes

n %

Value – The system must add value to the users – both clinicians and patients – and that value must be immediately visible. 48 39.7Usability – The system must have a user-friendly design and be simple to use 35 28.9Workflow – The system must fit into the clinical workflow of the unit and the clinicians. 27 22.3Advocates – Use early adopters to be local peer champions to drive uptake. 7 5.8Communication – Apps will have a core medical functionality, but to be most useful must include a simple-to-use communication function. 4 3.3

62 L. WALLIS ET AL.

Dow

nloa

ded

by [

Um

eå U

nive

rsity

Lib

rary

] at

01:

43 0

4 Ja

nuar

y 20

18

(39.7%), usability of mHealth apps (28.9%) and good-ness-of-fit into the work flow (22.3%).

Overcoming organizational barriers in health-care services

Table 4 presents the five strategies formulated in thesession concerning how to overcome organizationalbarriers in the health-care services. Three strategiesreceived at least 20% of the votes with the top onebeing related to the need for a strategy promotinggood-quality general ICT infrastructure (26.4%), clo-sely followed by the need to involve all relevantministries early in the process of developing or imple-menting mHealth tools (22.3%), and that of mHealthsolutions to promote quality standards and be inte-grated within the local health information system(20.7%). Related to the latter strategies is the onementioning the need of national mHealth strategieswith an interoperability framework. Finally, manyparticipants voted for the notion that organizationalbarriers could be lowered by the inclusion of cost-effectiveness analyses early in the development pro-cess, alongside the evaluation of diagnostic efficacy.

Overcoming technical barriers

Seven strategies were put forward to overcome tech-nical challenges and these cover a wide range ofaspects, from the need for basic infrastructure to beestablished (20.3%) to the creation of interoperabilitystandards (5.7%) (see Table 5). The need to simulta-neously understand local and regional needs, whilebuilding mHealth innovations for scale, was alsoviewed as an important strategy (19.5%) closely

followed by a strategy that encompasses severalimportant dimensions of image acquisition, proces-sing and transfer (18.7%). Two additional statementsdeemed important included the modification of reg-ulations to promote innovation (14.6%) and the useof multidisciplinary teams to lead develop-ment (14.6%).

Discussion

Reports and reviews on the state of knowledge regard-ing mHealth in sub-Saharan Africa or in some specificcountries are currently available. Some of them cover awide span of applications (the bulk of which remainbehavioural ones) [7] and others have a more specificfocus, like those related to non-communicable diseases(NCDs) [8]. Studies are reviewed for their theoreticalunderpinning, their methodological qualities, the stateof advancement of the ‘solution’ proposed and theiractual results. There is a general sense that there is anincreasing gap between what could be an interestingmHealth application (pilots) and what actually isimplemented and sustained; the criticism as to howresearch helps understand this gap is severe [7,8].Understanding how, why, for whom and in what cir-cumstances mHealth interventions improve treatmentand care is important [8].

Image-based mHealth innovations for cliniciansand public-health providers have the potential toimprove access and equity in health care; however,many stakeholders with complementary but distinctroles must be involved for such innovations to besuccessful [9]. Such stakeholders include researchers,who, for instance, will provide the evidence basenecessary to determine what the end users need,

Table 4. Which are the key strategies to overcome organizational challenges to the implementation of image-based mHealthwithin the health sector? (n = 121 votes).

Strategy

Votes

n %

mHealth initiatives should be aligned with other ICT infrastructure development strategies in a country. 32 26.4Ensure that all relevant ministries i.e. ministries of health, technology and education are included in the process. 27 22.3mHealth solutions should promote standards and be integrated with the local health-information system 25 20.7A national mHealth strategy with interoperability framework is needed 20 16.5Cost-effectiveness analyses of mHealth solutions should be included in the development process 17 14.0

Table 5. Which are the key strategies to overcome technical challenges in implementing image-based mHealth within thehealth sector? (n = 123 votes).

Strategy

Votes

n %

Basic infrastructure must be in place, including electricity and connectivity for mHealth to succeed 25 20.3Understand local context but build for scale 24 19.5By whom, how and where images are interpreted should be considered from a clinical, legal and technical point of view. 23 18.7Light-touch regulation and policy should remove hindrances and enable innovation 18 14.6Development should be led by a multidisciplinary team from the public and private sector, including technology experts 18 14.6Funding should not rely on end-user to pay 8 6.5Standards for interoperability should be set and easily available 7 5.7

GLOBAL HEALTH ACTION 63

Dow

nloa

ded

by [

Um

eå U

nive

rsity

Lib

rary

] at

01:

43 0

4 Ja

nuar

y 20

18

how to implement innovations successfully, and pre-dict what their expected efficacy will be. Another keystakeholder is government, who will provide infra-structures, regulatory frameworks (e.g. for the protec-tion of health information and the definition ofresponsibilities), and reimbursement models to createa suitable environment to implement mHealth inno-vations. Health-care providers will put into placesystems that help overcome individual barriers andlimitations felt by (too often overloaded) front-linehealth workers, protect health information andclearly address responsibility issues. Finally, partner-ships will also need to be created with the privatesector to address business-model issues such as cost-effectiveness, marketing and supply-chain issues.

The February roundtable created a space for sta-keholders from all these groups to debate key imple-mentation issues and to propose enabling strategies.Several of the enablers identified echo those put for-ward in other roadmaps [2–5] and a number of themcut across the subjects that were discussed from onesession to another at the roundtable.

Theme specific strategies

The most important ‘theme-specific’ strategies result-ing from the roundtable can be summarized as fol-lows. At an overarching level (first theme), it is crucialto ensure that the interface between existing infra-structures and mHealth innovations is seamless.Government policy is necessary to ensure regulationsuphold data security and privacy while also creating asuitable environment to facilitate mHealth innovationand implementation. A review of studies on mHealthapps for NCDs clearly reveals that regulatory policiesrank among the three most important enabling fac-tors of their implementation alongside the availabilityof a stable communications network and accessiblemaintenance services [8]. Indeed, as health practi-tioners around the world begin to embrace mobilehealth opportunities, regulatory frameworks mustdevelop further. This is to ensure that critical aspectssuch as individual privacy and confidentiality aremaintained, while still supporting innovations,empowering innovators and protecting patients andend-users.

When it comes to the front-line end-users (secondtheme), it appears clearly that disruptive modificationsof the work need to be anticipated, dealt with and coun-terbalanced not only by acting on their acceptability andusability but also by their compatibility and added value.This is really important as a recent review shows that, inthe case of NCDs, only if providers believe that mHealthinterventions are useful and easy to use will mHealthultimately contribute to improved access to care [8].

To address these issues in a structured and pro-ductive manner requires prospective appraisal of

potential projects utilizing appropriate planningtools and a health-systems perspective [10]. Thiswill help to promote project success and is particu-larly important for planning for scale. The WHO’sMAPS Toolkit (mHealth Assessment and Planningfor Scale) [11] provides useful guidance, as does thenewly released WHO guide for Planning DigitalHealth Mobile Interventions [12]. From another per-spective, it can be of interest to investigate further thereasons for the success of consumer-oriented basedapps like Viber or WhatsApp among clinicians whenseeking advice [12,13] in spite of the many issues ofprivacy and security that they entail.

From an organizational point of view (thirdtheme), the quality of the ICT infrastructure of thehealth-care services in place is also seen as veryimportant. Rather than acting in silos, the implemen-tation of mHealth solutions should involve all rele-vant ministries during early stages of developmentand that data entered into any platform should beharmonized between the applications and the localhealth-information system. This will likely facilitategreater use of mHealth innovations by end-users asdata entry is not duplicated. This was evaluated inearlier studies [12–14] where there are the needs ofan interoperability framework and of standards forboth exchange of data between systems and for sto-rage of health-related data in local and national repo-sitories. Cost-effectiveness analyses early in thedevelopment process, alongside the evaluation ofdiagnostic efficacy, were also seen as potentialenabling factors. As regards the technology (fourththeme), the stakeholders present at the roundtableproposed several related strategies that could helpovercome technical barriers; they varied much inscope and nature with the need for basic infrastruc-ture, the need to pay attention to the local context,and the need to be aware of the many dimensions tobe considered when transferring images ranking high.

It is of note that the technical environment sur-rounding image-based mHealth applications actuallyincludes many components: electricity (in grid or outof grid); mobile (high-speed) data coverage; smart-phones and applications; central or cloud-basedinformation-storage and sharing systems; scannersand picture-presentation systems; systems to supportexpert access to data and images stored in the cloud;and patient journal systems for diagnosis feedbackand storage. Whereas some components only needto be in place for specific sites, trials or pilots, all areneeded to scale a given application, and even tostimulate technical innovation and investments inmHealth technology. Also, the first four componentsof the technical environment for mobile health arenot specific to the health sector. They are neededacross a wide range of social and industrial sectorsand highlight the importance of integrated planning

64 L. WALLIS ET AL.

Dow

nloa

ded

by [

Um

eå U

nive

rsity

Lib

rary

] at

01:

43 0

4 Ja

nuar

y 20

18

and sharing of technology assets for optimal socio-economic return.

What basic infrastructures are available and theirquality vary enormously globally and on the Africancontinent as well as in other resource-scarce settings,both between and within countries (see some exam-ples in Table 6). Their availability and affordabilitydepend most often on governmental investment orregulation. The need for a technical foundation iswell acknowledged in a number of African countries’National eHealth Strategies [15–18]*** and eHealthstrategies [19]. The importance of this foundation isnot trivial, since they are fundamental to working inthe mobile digital environment.

Strategies across themes

Not surprisingly, the ease of integration of the mHealthapplications into existing infrastructure was put for-ward not only when discussing overarching issues, butalso barriers more specific to front-line users andothers related to the health-care organization.Beyond acceptability and usability, some put forwardnot only seamlessness but also added value, in parti-cular as regards front-line users. This is in line with thenecessity expressed by a number of participants tometiculously conceive the solutions/applications envi-saged and come up with solid proof of cost-effective-ness [7]. There is indeed a paucity of cost-utility andcost-effectiveness studies available within the field ofmHealth [19].

An additional aspect that cuts across severalthemes is the need for a solid ICT infrastructure andof a support network to be in place. Whereas this maybe challenging in specific geographic areas or health-care units, the participants underlined the necessityto look at the issue in a broader perspective andinvolve a wider range of stakeholders (within andoutside the health sector). And there are good reasonsto believe that motivation to improve the ICT infra-structure in a country – such as mobile networks –might be strengthened by alignment of mHealthinitiatives with other ones in the society that wouldbenefit from improved connectivity [15]. Local smallbusinesses, agriculture, schools and universities arelikely to benefit equally to a local, rural hospital ordoctor’s office if connectivity is improved. In fact, thepoint has been made that ICTs can facilitate the

implementation of the Sustainable DevelopmentGoals (SDGs) [20].

Interoperability is a third cross-cutting elementworth mentioning. It applies not only to local orregional environments but also to national andcross-border ones. Interoperability is crucial for thepossibility of knowledge sharing and data transferbetween both organizations and countries, as well asfor scaling the deployment. South Africa, for exam-ple, adds Interoperability to its list of eHealth foun-dation elements, and has developed a NormativeHealth Standards Framework [21] to help guide thesector. Another aspect of inter-operability is thepotential to collect large repositories of cases withknown outcome, together with images and associatedclinical data. These digital repositories should prefer-ably be accessible across institutions and nations fordevelopment of computer-assisted decision-supportsolutions and artificial intelligence-based algorithms.

Strengths and limitations

Embarked upon to establish key elements of a firstroadmap for the implementation of image-basedmHealth applications for advice and support amongclinicians, this study has a number of strengths thatare worth mentioning. One is the long and knowl-edge-driven preparation of the event where the dis-cussions took place, a preparation that involved acore group of stakeholders from different contextsand professions. An additional strength is the focuson those aspects that are most critical at the time ofimplementation of mHealth solutions, i.e. user, orga-nization, technology and the will to discuss howbarriers can be overcome and what enabling factorscan be put into place. The event also managed togather participants with diverse backgrounds – coun-try, professional background, areas in society and soon and provided them with ample opportunities tolisten, exchange and express their views and concernsbased on their perspectives and contexts.

A drawback of approaches of the kind we have chosenhowever is that people come on a voluntary basis andrepresent their own perspective rather than that of theirorganization and the representation obtainedmay not beas expected. At this roundtable, as in previous ones, wehad an under-representation of the business sector and ofpolicymakers. Thismayhave influenced the strategies putforward, if not in their definition in the priority they havereceived. There are several reasons that contribute toexplain this under-representation. One is the predomi-nance of researchers in the groupof people that organizedthe meeting, which may have limited our ability to reachout to policymakers and people from the business sectorfrom the beginning. Another reason, linked to the firstone, is that by tradition, the interface between research,policy and business in meetings with themes such as the

Table 6. Examples of differences in the distribution oftechnical resources in the sub-Saharan Africa (SSA) region(in % of population).Country Malawi % Ethiopia % South Africa %

Electricity – urban 32 85 90Electricity – rural 4 10 77Internet users 9 12 52

Source: Factbook.

GLOBAL HEALTH ACTION 65

Dow

nloa

ded

by [

Um

eå U

nive

rsity

Lib

rary

] at

01:

43 0

4 Ja

nuar

y 20

18

one our meeting conveyed does not unfold naturally.Policymakers and people from the business sector arenot familiar with such events, may experience them asunnecessarily challenging and time consuming, andhence do not give them high priority. Eventually,approaching business organizations rather than indivi-dual companies could have been more fruitful, as theformer are more used to such events. Likewise, invitingcivil servants rather thanministers themselves could haveprovided the input that is necessary to move forwardwithout exposing politicians to discuss sensitive ques-tions. A third explanation relates to the very topic of themeeting, which may have lacked clarity regarding whatwould actually be discussed, as the subject of health-careinnovation in general tends to be unclear for healthpolicymakers and practitioners and [22]. When thetopic itself will become clearer to those stakeholders andthey can see their role, it may become easier to raise theirinterest. Inevitably, in a foreseeable future policymakerswill need to take into consideration the fact that mHealthwill be more or less omnipresent in health care and thiswill force them to engage and be proactive not least asregardsmobile health education, delivery and integration[23]. And there are reasons to be optimistic in that respectas, just in the sub-Saharan Africa context, there is evi-dence of strong collaboration among stakeholders (2014)when implementing mHealth innovations [1].

The final wording of the strategies derived fromeach session was determined by the moderators ofthe session, assisted by plenum secretaries. The mod-erators had experience of the domain considered andthey were instructed to remain as close as possible towhat was expressed. We assumed that the strategiesformulated reflected well what had been exposed at theplenary sessions, but we do not know how differentlythey would have been formulated should other mod-erators have been in charge.

An additional limitation is that we did not cover allsix aspects that are relevant to the elaboration of aroadmap (Figure 2). Nonetheless, with the exceptionof the clinical guidelines and medical ethics, most ofthem were raised in the context of the chosen themes(e.g. patient security and safety, standards and inter-operability, connectivity). We did not pay attention toclinical specialists themselves as a group of users,something that other roadmaps have done [5] or, forthat matter, to patients.

It is not easy to assess how more concrete in thestrategies proposed we could have been, given the sizeand the diversity of the group and also the timeavailable, but this was not the primary aim of theprocess or this roadmap.

Conclusions

Image-based diagnosis is a field of research in full expan-sion and the foreseeable technological developments

offer great promises in making health care more acces-sible and thereby reducing the health divide. This appliesto applications for diagnostic and treatment assistance inacute phases of disease or trauma and even, perhapsincreasingly, to applications that could even provide foraccurate prognosis relative to patient outcome and sup-port decision-making on treatment. Further, the forma-tion of joint and broadly accessible image libraries withexpert annotations received strong support from theparticipants who saw that as a proactive strategy thatcould greatly contribute to both academia and industryin the era of digital medicine and artificial and augmen-ted intelligence.

At the moment, however, the flow of financialsupport into the field is, to say the least, shy, and atthe same time there are very few convincing proofs ofconcept. An additional preoccupation is that policytraditionally does not develop rapidly and, in thiscase, may hinder the implementation of highly cost-saving ground-breaking digital tools in the medicalfield that can create, among others, opportunities forreimbursement – of development costs or of digitalservices provided.

We may also be at a time where applications areimplemented in an isolated manner, something thatconsumes time and efforts from all partiesinvolved. Eventually, windows of opportunitieswill arise for payer–provider win–win in healthsystems, for instance when new applications willeasily be introduced within mHealth platformsalready in place: systems that are known, custo-mized and trusted.

Acknowledgments

The article was published thanks to financial support fromthe Wallenberg Foundation and Umeå University.

Author contributions

LL, MH and LW elaborated the idea of this study. LL, LW,MH, CB, SB, JG, JNB, PN, MO and LW contributed to thepreparation of the meeting, including recruitment of parti-cipants, development of the programme and determinationof the questions to be addressed. LL, LW, MH, SB, GD, IBand LW chaired sessions and summarized the strategiesemerging from them. LL, LW and MH prepared the firstdraft of the paper. All authors made significant contribu-tions to the paper. All authors approved the final version.

Disclosure statement

No potential conflict of interest was reported by theauthors.

Ethics and consent

Not required.

66 L. WALLIS ET AL.

Dow

nloa

ded

by [

Um

eå U

nive

rsity

Lib

rary

] at

01:

43 0

4 Ja

nuar

y 20

18

Funding information

None.

Paper context

Image-based diagnostic assistance can significantlyreduce the burden of disease and its unequal socialdistribution and impact. The absence of a roadmap forthe implementation of such applications in clinical set-tings is an obstacle. Stakeholders gathered at a two-dayroundtable helped develop such a roadmap, focusing onissues relative to front-line users and organizational andtechnical environments. Successful implementation ofmHealth solutions necessitates a seamless introductioninto routines, adequate technical support and significantadded value.

ORCID

Lee Wallis http://orcid.org/0000-0003-2711-3139Peter Nyasulu http://orcid.org/0000-0003-2757-0663

References

[1] Aranda-Jan CB, Mohutsiwa-Dibe N, Loukanova S.Systematic review on what works, what does not workand why of implementation of mobile health (mHealth)projects in Africa. BMC Public Health. 2014;14:188.

[2] The HIMSS mHealth roadmap – an overview.Chicago (IL): Healthcare Information andManagement Systems Society; 2015 [cited 2017 Mar31]. Available from: http://www.himss.org/himss-mhealth-roadmap-overview

[3] Groupe Mobile Speciale Association. The GSMAmHealth Grand Tour: Making a Roadmap formHealth. 2015 [cited 2017 Mar 31]. Available from:http://www.gsma.com/iot/iot-knowledgebase/gsma-mhealth-grand-tour-case-study/

[4] PMLive: Digital intelligence blog. PMLive. Europe’sdeveloping roadmap for mHealth use and acceptance.2012 [cited 2017 Mar 31]. Available from: http://www.pmlive.com/blogs/digital_intelligence/archive/2012/september/europe_developing_roadmap_for_mhealth_use_and_acceptance_424407

[5] Eapen ZJ, Mintu P, Turakhia P, et al. Defining amobile health roadmap for cardiovascular health anddisease. J Am Heart Assoc. 2016;5:e003119.

[6] Stias news. Stellenbosch Institute for Advanced Study.Stellenbosch, South Africa. Implementing image-based mobile technology for diagnostics and treat-ment to improve access and equity in health care –STIAS-Wallenberg Roundtable on mHealth. 2017[cited 2017 Mar 31]. Available from: http://stias.ac.za/news/2017/02/implementing-image-based-mobile-technology-for-diagnostics-and-treatment-to-improve-access-and-equity-in-health-care-stias-wallenberg-roundtable-on-mhealth/

[7] Tomlinson M, Rotheram-Borus M, Swartz L, et al.Scaling up mHealth: where is the evidence? PLoSMed. 2013;10:e1001382.

[8] Opuku D, Stephani V, Quentin W. A realist review ofmobile phone-based health interventions for non-communicable disease management in sub-SaharanAfrica. BMC Med. 2017;15:24.

[9] Lemaire M Scaling up mobile health - Elements neces-sary for the successful scale up of mHealth in devel-oping countries. K4Health; 2011 [cited 2017 Mar 31].Available from: http://www.k4health.org/sites/default/files/ADA_mHealthWhite Paper.pdf

[10] World Health Organisation. Geneva: The MAPSToolkit: mHealth Assessment and Planning for Scale;2015 [cited 2017 Mar 31]. Available from: http://www.who.int/iris/handle/10665/185238

[11] Leon N, Schneider H, Daviaud E. Applying a frame-work for assessing the health system challenges toscaling up mHealth in South Africa. BMC MedInform Decis Mak. 2012;12:123.

[12] World Health Organisation. Geneva, Switzerland.Guidelines for Recommendations on Digital HealthInterventions for RMNCAH and Health SystemsStrengthening. 2016 [cited 2017 Mar 15]. Availablefrom: http://www.who.int/reproductivehealth/topics/mhealth/digital-health-interventions/en/

[13] Mars M, Scott RE. Being spontaneous: the future oftelehealth implementation? Telemed E-Health.2017;23:1–7.

[14] Mars M, Scott RE. WhatsApp in clinical practice: Aliterature review. Stud Health Technol Inform.2016;231:82–90.

[15] National Department of Health, Republic of SouthAfrica. eHealth Strategy South Africa. 2012 [cited2017 Mar 24].

[16] Ministry of Health and Social Welfare, The UnitedRepublic of Tanzania. Tanzanian National eHealthStrategy 2013 – 2018. 2013 [cited 2017 Mar 24].Available from: http://www.who.int/goe/policies/countries/tza_ehealth.pdf

[17] Ghana Ministry of Health. National eHealth Strategy;2011 [cited 2017 Mar 25]. Available from: http://www.nita.gov.gh/sites/default/files/Ghana_E-Health_Strategy.pdf

[18] National Department of Health, Republic of SouthAfrica. mHealth Strategy 2015 – 2019. 2015 [cited2017 Mar 25]. Available from: http://www.hst.org.za/publications/mhealth-strategy-2015-2019

[19] De la Torre-Díez I, López-Coronado M, Vaca C, et al.Cost-utility and cost-effectiveness studies of telemedi-cine, electronic, and mobile health systems in theliterature: A systematic review. Telemed J E Health.2015;21:81–85.

[20] Leusse CBD. 2015. The Internet and SustainableDevelopment. Geneva: Internet Society. Availablefrom: https://www.internetsociety.org/sites/default/files/ISOC-ICTs-SDGs-201506-1.pdf

[21] National Department of Health, Republic of South Africa.2014 [cited 2017 Mar 15]. Available from: http://www.gov.za/sites/www.gov.za/files/37583_gen314.pdf

[22] Omachonu VK, Einspruch NG. Innovation in health-care delivery systems: a conceptual framework. InnovJ. 2010;15.

[23] Scott RE, Mars M. Telehealth in the developing world:current status and future prospects. Smart HomecareTechnol Telehealth. 2015;3:25–37.

GLOBAL HEALTH ACTION 67

Dow

nloa

ded

by [

Um

eå U

nive

rsity

Lib

rary

] at

01:

43 0

4 Ja

nuar

y 20

18