register interest

Chris Paton

Research Area: Global Health
Scientific Themes: Tropical Medicine & Global Health and Clinical Trials & Epidemiology

Dr Chris Paton is the Head of the Global Health Informatics Group at the University of Oxford. His research group investigates how new digital health technologies such as electronic health records (EHRs), mHealth apps, and new machine learning techniques can be used to improve healthcare.

Following his training as a medical doctor in the UK, he moved into Clinical Informatics and worked as a Senior Research Fellow at the National Institute for Health Innovation in New Zealand before returning to the UK to join the University of Oxford. He received his Fellowship of the UK Faculty of Clinical Informatics in 2018 and became an Official Fellow of Parks College, Oxford in 2019.

He is the Principal Investigator for the LIFE (Life-saving Instruction for Emergencies) project. LIFE is a smartphone-based simulation training platform that uses a virtual hospital. environment to simulate medical emergencies to train healthcare workers. Launched in April 2019, LIFE has now been downloaded by thousands of healthcare workers in Africa and Dr Paton is now leading a clinical trial of the platform in Kenya funded by GCRF. See here for a BBC interview about the project.

Dr Paton collaborates on several large-scale international projects including NEST360, a £50 million initiative that aims to deliver new technologies and training to improve neonatal care in Africa and a new Wellcome Trust Innovation Flagship in Vietnam that will develop and implement a range of new AI-based monitoring devices in intensive care units (ICUs) in South-East Asia.

He currently supervises 3 DPhil students at the University of Oxford with Professor Niall Winters in the Department of Education and Professor Mike English at the Nuffield Department of Medicine. He also lectures and supervises students for the Masters in International Health and Tropical Medicine.

Dr Paton has served as a digital health consultant the New Zealand Government and the Pathways for Prosperity Commission. He co-founded and chaired the International Medical Informatics Association (IMIA) social media working group and is currently co-chair of the IMIA open source working group. He is Associate Editor of “Digital Health Journal” (Sage Publishing) and “BMC: Medical Informatics and Decision Making”. He is a peer reviewer on digital health topics for scientific journals including Nature, PLOS One, JAMIA, JMIR, ANZJPH and serves as an expert grant reviewer for the UK’s Medical Research Council, the Research Council of Norway. He is also the Founder and Editor of the Health Informatics Forum, an online professional learning community that offers free courses, seminars and online discussion with a membership of over 11,000 health informatics professionals around the world.

Name Department Institution Country
Mike English Tropical Medicine Oxford University, Nairobi Kenya
Associate Professor John Powell Nuffield Department of Primary Care Health Sciences University of Oxford United Kingdom
Associate Professor Hamish Fraser University of Leeds United Kingdom
Associate Professor Niall Winters Department of Education Oxford University United Kingdom
Dr Hilary Edgcombe Nuffield Department of Clinical Neurosciences Oxford University United Kingdom
Sheik-Ali S, Edgcombe H, Paton C. 2019. Next-generation Virtual and Augmented Reality in Surgical Education: A Narrative Review. Surg Technol Int, 35 pp. 27-35. | Show Abstract

BACKGROUND: Virtual and Augmented Reality (VR/AR) has been used in surgery for several decades. Over the past 5-10 years, however, new technological advances, including high-resolution screens, mobile graphical processing units (mGPUs) and position-sensing technologies, have been incorporated into relatively low-cost VR and AR devices. This review focuses on the current impact of the application of these "Phase 2" VR/AR technology in surgical training. METHODS: A narrative literature review was undertaken using PubMed and Web of Science to identify comparative studies related to the impact of Phase 2 VR or AR tools on surgical training, defined in terms of the acquisition of technical surgical skills. Eleven studies on the effectiveness of VR/AR in surgical education were identified for full review. Further, the grey literature was searched for articles describing the current state of VR/AR in surgical education. A quality analysis using the Newcastle Ottawa scale showed a median score of 7 (out of a maximum achievable score of 9). RESULTS: All studies showed a positive association between the use of VR/AR in surgical training and skill acquisition in terms of improving the speed of acquisition of surgical skills, the surgeon's ability to multitask, the ability to perform a procedure accurately, hand-eye coordination and bimanual operation. The grey literature presented a common, positive theme of the benefits of VR/AR in surgical training. CONCLUSIONS: Based on the limited evidence available, VR/AR appears to have positive training benefits in improving the speed of acquisition of surgical skills. However, the significant heterogeneity in study methodology and the relative recency of wider VR/AR adoption in surgical training mean that only tentative conclusions can be drawn at this stage. Further research, ideally with large sample sizes, robust outcome measures and longer follow-up periods, is recommended.

Tuti T, Winters N, Muinga N, Wanyama C, English M, Paton C. 2019. Evaluation of Adaptive Feedback in a Smartphone-Based Serious Game on Health Care Providers' Knowledge Gain in Neonatal Emergency Care: Protocol for a Randomized Controlled Trial. JMIR Res Protoc, 8 (7), pp. e13034. | Show Abstract | Read more

BACKGROUND: Although smartphone-based clinical training to support emergency care training is more affordable than traditional avenues of training, it is still in its infancy and remains poorly implemented. In addition, its current implementations tend to be invariant to the evolving learning needs of the intended users. In resource-limited settings, the use of such platforms coupled with serious-gaming approaches remain largely unexplored and underdeveloped, even though they offer promise in terms of addressing the health workforce skill imbalance and lack of training opportunities associated with the high neonatal mortality rates in these settings. OBJECTIVE: This randomized controlled study aims to assess the effectiveness of offering adaptive versus standard feedback through a smartphone-based serious game on health care providers' knowledge gain on the management of a neonatal medical emergency. METHODS: The study is aimed at health care workers (physicians, nurses, and clinical officers) who provide bedside neonatal care in low-income settings. We will use data captured through an Android smartphone-based serious-game app that will be downloaded to personal phones belonging to the study participants. The intervention will be adaptive feedback provided within the app. The data captured will include the level of feedback provided to participants as they learn to use the mobile app, and performance data from attempts made during the assessment questions on interactive tasks participants perform as they progress through the app on emergency neonatal care delivery. The primary endpoint will be the first two complete rounds of learning within the app, from which the individuals' "learning gains" and Morris G intervention effect size will be computed. To minimize bias, participants will be assigned to an experimental or a control group by a within-app random generator, and this process will be concealed to both the study participants and the investigators until the primary endpoint is reached. RESULTS: This project was funded in November 2016. It has been approved by the Central University Research Ethics Committee of the University of Oxford and the Scientific and Ethics Review Unit of the Kenya Medical Research Institute. Recruitment and data collection began from February 2019 and will continue up to July 31, 2019. As of July 18, 2019, we enrolled 541 participants, of whom 238 reached the primary endpoint, with a further 19 qualitative interviews conducted to support evaluation. Full analysis will be conducted once we reach the end of the study recruitment period. CONCLUSIONS: This study will be used to explore the effectiveness of adaptive feedback in a smartphone-based serious game on health care providers in a low-income setting. This aspect of medical education is a largely unexplored topic in this context. In this randomized experiment, the risk of performance bias across arms is moderate, given that the active ingredient of the intervention (ie, knowledge) is a latent trait that is difficult to comprehensively control for in a real-world setting. However, the influence of any resulting bias that has the ability to alter the results will be assessed using alternative methods such as qualitative interviews. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR201901783811130; https://pactr.samrc.ac.za/TrialDisplay. aspx?TrialID=5836. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/13034.

Winters N, Langer L, Nduku P, Robson J, O'Donovan J, Maulik P, Paton C, Geniets A, Peiris D, Nagraj S. 2019. Using mobile technologies to support the training of community health workers in low-income and middle-income countries: mapping the evidence. BMJ Glob Health, 4 (4), pp. e001421. | Show Abstract | Read more

Introduction: This paper maps the evidence published between 2000 and 2018 on the use of mobile technologies to train community health workers (CHWs) in low- and middle-income countries (LMICs) across nine areas of global healthcare, including the neglected areas of disability and mental health. Methods: We used an evidence mapping methodology, based on systematic review guidelines, to systematically and transparently assess the available evidence-base. We searched eight scientific databases and 54 grey literature sources, developed explicit inclusion criteria, and coded all included studies at full text for key variables. The included evidence-base was visualised and made accessible through heat mapping and the development of an online interactive evidence interface. Results: The systematic search for evidence identified a total of 2530 citations of which 88 met the full inclusion criteria. Results illustrate overall gaps and clusters of evidence. While the evidence map shows a positive shift away from information dissemination towards approaches that use more interactive learner-centred pedagogies, including supervision and peer learning, this was not seen across all areas of global health. Areas of neglect remain; no studies of trauma, disability, nutrition or mental health that use information dissemination, peer learning or supervision for training CHWs in LMICs were found. Conclusion: The evidence map shows significant gaps in the use of mobile technologies for training, particularly in the currently neglected areas of global health. Significant work will be needed to improve the evidence-base, including assessing the quality of mobile-based training programmes.

Paton C, Kobayashi S. 2019. An Open Science Approach to Artificial Intelligence in Healthcare. Yearb Med Inform, 28 (1), pp. 47-51. | Show Abstract | Read more

OBJECTIVES: Artificial Intelligence (AI) offers significant potential for improving healthcare. This paper discusses how an "open science" approach to AI tool development, data sharing, education, and research can support the clinical adoption of AI systems. METHOD: In response to the call for participation for the 2019 International Medical Informatics Association (IMIA) Yearbook theme issue on AI in healthcare, the IMIA Open Source Working Group conducted a rapid review of recent literature relating to open science and AI in healthcare and discussed how an open science approach could help overcome concerns about the adoption of new AI technology in healthcare settings. RESULTS: The recent literature reveals that open science approaches to AI system development are well established. The ecosystem of software development, data sharing, education, and research in the AI community has, in general, adopted an open science ethos that has driven much of the recent innovation and adoption of new AI techniques. However, within the healthcare domain, adoption may be inhibited by the use of "black-box" AI systems, where only the inputs and outputs of those systems are understood, and clinical effectiveness and implementation studies are missing. CONCLUSIONS: As AI-based data analysis and clinical decision support systems begin to be implemented in healthcare systems around the world, further openness of clinical effectiveness and mechanisms of action may be required by safety-conscious healthcare policy-makers to ensure they are clinically effective in real world use.

Kobayashi S, Kane TB, Paton C. 2018. The Privacy and Security Implications of Open Data in Healthcare. Yearb Med Inform, 27 (1), pp. 41-47. | Show Abstract | Read more

OBJECTIVE:  The International Medical Informatics Association (IMIA) Open Source Working Group (OSWG) initiated a group discussion to discuss current privacy and security issues in the open data movement in the healthcare domain from the perspective of the OSWG membership. METHODS:  Working group members independently reviewed the recent academic and grey literature and sampled a number of current large-scale open data projects to inform the working group discussion. RESULTS:  This paper presents an overview of open data repositories and a series of short case reports to highlight relevant issues present in the recent literature concerning the adoption of open approaches to sharing healthcare datasets. Important themes that emerged included data standardisation, the inter-connected nature of the open source and open data movements, and how publishing open data can impact on the ethics, security, and privacy of informatics projects. CONCLUSIONS:  The open data and open source movements in healthcare share many common philosophies and approaches including developing international collaborations across multiple organisations and domains of expertise. Both movements aim to reduce the costs of advancing scientific research and improving healthcare provision for people around the world by adopting open intellectual property licence agreements and codes of practice. Implications of the increased adoption of open data in healthcare include the need to balance the security and privacy challenges of opening data sources with the potential benefits of open data for improving research and healthcare delivery.

Muinga N, Magare S, Monda J, Kamau O, Houston S, Fraser H, Powell J, English M, Paton C. 2018. Implementing an Open Source Electronic Health Record System in Kenyan Health Care Facilities: Case Study. JMIR Med Inform, 6 (2), pp. e22. | Show Abstract | Read more

BACKGROUND: The Kenyan government, working with international partners and local organizations, has developed an eHealth strategy, specified standards, and guidelines for electronic health record adoption in public hospitals and implemented two major health information technology projects: District Health Information Software Version 2, for collating national health care indicators and a rollout of the KenyaEMR and International Quality Care Health Management Information Systems, for managing 600 HIV clinics across the country. Following these projects, a modified version of the Open Medical Record System electronic health record was specified and developed to fulfill the clinical and administrative requirements of health care facilities operated by devolved counties in Kenya and to automate the process of collating health care indicators and entering them into the District Health Information Software Version 2 system. OBJECTIVE: We aimed to present a descriptive case study of the implementation of an open source electronic health record system in public health care facilities in Kenya. METHODS: We conducted a landscape review of existing literature concerning eHealth policies and electronic health record development in Kenya. Following initial discussions with the Ministry of Health, the World Health Organization, and implementing partners, we conducted a series of visits to implementing sites to conduct semistructured individual interviews and group discussions with stakeholders to produce a historical case study of the implementation. RESULTS: This case study describes how consultants based in Kenya, working with developers in India and project stakeholders, implemented the new system into several public hospitals in a county in rural Kenya. The implementation process included upgrading the hospital information technology infrastructure, training users, and attempting to garner administrative and clinical buy-in for adoption of the system. The initial deployment was ultimately scaled back due to a complex mix of sociotechnical and administrative issues. Learning from these early challenges, the system is now being redesigned and prepared for deployment in 6 new counties across Kenya. CONCLUSIONS: Implementing electronic health record systems is a challenging process in high-income settings. In low-income settings, such as Kenya, open source software may offer some respite from the high costs of software licensing, but the familiar challenges of clinical and administration buy-in, the need to adequately train users, and the need for the provision of ongoing technical support are common across the North-South divide. Strategies such as creating local support teams, using local development resources, ensuring end user buy-in, and rolling out in smaller facilities before larger hospitals are being incorporated into the project. These are positive developments to help maintain momentum as the project continues. Further integration with existing open source communities could help ongoing development and implementations of the project. We hope this case study will provide some lessons and guidance for other challenging implementations of electronic health record systems as they continue across Africa.

Paton C, Karopka T. 2017. The Role of Free/Libre and Open Source Software in Learning Health Systems. Yearb Med Inform, 26 (1), pp. 53-58. | Show Abstract | Read more

Objective: To give an overview of the role of Free/Libre and Open Source Software (FLOSS) in the context of secondary use of patient data to enable Learning Health Systems (LHSs). Methods: We conducted an environmental scan of the academic and grey literature utilising the MedFLOSS database of open source systems in healthcare to inform a discussion of the role of open source in developing LHSs that reuse patient data for research and quality improvement. Results: A wide range of FLOSS is identified that contributes to the information technology (IT) infrastructure of LHSs including operating systems, databases, frameworks, interoperability software, and mobile and web apps. The recent literature around the development and use of key clinical data management tools is also reviewed. Conclusions: FLOSS already plays a critical role in modern health IT infrastructure for the collection, storage, and analysis of patient data. The nature of FLOSS systems to be collaborative, modular, and modifiable may make open source approaches appropriate for building the digital infrastructure for a LHS.

Tuti T, Nzinga J, Njoroge M, Brown B, Peek N, English M, Paton C, van der Veer SN. 2017. A systematic review of electronic audit and feedback: intervention effectiveness and use of behaviour change theory. Implement Sci, 12 (1), pp. 61. | Show Abstract | Read more

BACKGROUND: Audit and feedback is a common intervention for supporting clinical behaviour change. Increasingly, health data are available in electronic format. Yet, little is known regarding if and how electronic audit and feedback (e-A&F) improves quality of care in practice. OBJECTIVE: The study aimed to assess the effectiveness of e-A&F interventions in a primary care and hospital context and to identify theoretical mechanisms of behaviour change underlying these interventions. METHODS: In August 2016, we searched five electronic databases, including MEDLINE and EMBASE via Ovid, and the Cochrane Central Register of Controlled Trials for published randomised controlled trials. We included studies that evaluated e-A&F interventions, defined as a summary of clinical performance delivered through an interactive computer interface to healthcare providers. Data on feedback characteristics, underlying theoretical domains, effect size and risk of bias were extracted by two independent review authors, who determined the domains within the Theoretical Domains Framework (TDF). We performed a meta-analysis of e-A&F effectiveness, and a narrative analysis of the nature and patterns of TDF domains and potential links with the intervention effect. RESULTS: We included seven studies comprising of 81,700 patients being cared for by 329 healthcare professionals/primary care facilities. Given the extremely high heterogeneity of the e-A&F interventions and five studies having a medium or high risk of bias, the average effect was deemed unreliable. Only two studies explicitly used theory to guide intervention design. The most frequent theoretical domains targeted by the e-A&F interventions included 'knowledge', 'social influences', 'goals' and 'behaviour regulation', with each intervention targeting a combination of at least three. None of the interventions addressed the domains 'social/professional role and identity' or 'emotion'. Analyses identified the number of different domains coded in control arm to have the biggest role in heterogeneity in e-A&F effect size. CONCLUSIONS: Given the high heterogeneity of identified studies, the effects of e-A&F were found to be highly variable. Additionally, e-A&F interventions tend to implicitly target only a fraction of known theoretical domains, even after omitting domains presumed not to be linked to e-A&F. Also, little evaluation of comparative effectiveness across trial arms was conducted. Future research should seek to further unpack the theoretical domains essential for effective e-A&F in order to better support strategic individual and team goals.

Chantler T, Paton C, Velardo C, Triantafyllidis A, Shah SA, Stoppani E, Conrad N, Fitzpatrick R, Tarassenko L, Rahimi K. 2016. Creating connections - the development of a mobile-health monitoring system for heart failure: Qualitative findings from a usability cohort study. Digit Health, 2 pp. 2055207616671461. | Show Abstract | Read more

Objective: There is significant interest in the role of digital health technology in enabling optimal monitoring of heart failure patients. To harness this potential, it is vital to account for users' capacity and preferences in the development of technological solutions. We adopted an iterative approach focussed on learning from users' interactions with a mobile-health monitoring system. Methods: We used a participatory mixed methods research approach to develop and evaluate a mobile-health monitoring system. Fifty-eight heart failure patients were recruited from three health care settings in the UK and provided with Internet-enabled tablet computers that were wirelessly linked to sensor devices for blood pressure, heart rate and weight monitoring. One to two home visits were conducted with a subgroup of 29 participants to evaluate the usability of the system over a median follow-up period of six months. The thematic analysis of observational data and 45 interviews was informed by the domestication of technology theory. Results: Our findings indicate that digital health technologies need to create and extend connections with health professionals, be incorporated into users' daily routines, and be personalised according to users' technological competencies and interest in assuming a proactive or more passive role in monitoring their condition. Conclusions: Users' patterns of engagement with health technology changes over time and varies according to their need and capacity to use the technology. Incorporating diverse user experiences in the development and maintenance of mobile-health systems is likely to increase the extent of successful uptake and impacts on outcomes for patients and providers.

Kumar P, Paton C, Kirigia D. 2016. I've got 99 problems but a phone ain't one: Electronic and mobile health in low and middle income countries. Arch Dis Child, 101 (10), pp. 974-979. | Show Abstract | Read more

Mobile technology is very prevalent in Kenya-mobile phone penetration is at 88% and mobile data subscriptions form 99% of all internet subscriptions. While there is great potential for such ubiquitous technology to revolutionise access and quality of healthcare in low-resource settings, there have been few successes at scale. Implementations of electronic health (e-Health) and mobile health (m-Health) technologies in countries like Kenya are yet to tackle human resource constraints or the political, ethical and financial considerations of such technologies. We outline recent innovations that could improve access and quality while considering the costs of healthcare. One is an attempt to create a scalable clinical decision support system by engaging a global network of specialist doctors and reversing some of the damaging effects of medical brain drain. The other efficiently extracts digital information from paper-based records using low-cost and locally produced tools such as rubber stamps to improve adherence to clinical practice guidelines. By bringing down the costs of remote consultations and clinical audit, respectively, these projects offer the potential for clinics in resource-limited settings to deliver high-quality care. This paper makes a case for continued and increased investment in social enterprises that bridge academia, public and private sectors to deliver sustainable and scalable e-Health and m-Health solutions.

Edgcombe H, Paton C, English M. 2016. Enhancing emergency care in low-income countries using mobile technology-based training tools. Arch Dis Child, 101 (12), pp. 1149-1152. | Show Abstract | Read more

In this paper, we discuss the role of mobile technology in developing training tools for health workers, with particular reference to low-income countries (LICs). The global and technological context is outlined, followed by a summary of approaches to using and evaluating mobile technology for learning in healthcare. Finally, recommendations are made for those developing and using such tools, based on current literature and the authors' involvement in the field.

Tuti T, Bitok M, Malla L, Paton C, Muinga N, Gathara D, Gachau S, Mbevi G, Nyachiro W, Ogero M et al. 2016. Improving documentation of clinical care within a clinical information network: an essential initial step in efforts to understand and improve care in Kenyan hospitals. BMJ Glob Health, 1 (1), pp. e000028. | Show Abstract | Read more

In many low income countries health information systems are poorly equipped to provide detailed information on hospital care and outcomes. Information is thus rarely used to support practice improvement. We describe efforts to tackle this challenge and to foster learning concerning collection and use of information. This could improve hospital services in Kenya. We are developing a Clinical Information Network, a collaboration spanning 14 hospitals, policy makers and researchers with the goal of improving information available on the quality of inpatient paediatric care across common childhood illnesses in Kenya. Standardised data from hospitals' paediatric wards are collected using non-commercial and open source tools. We have implemented procedures for promoting data quality which are performed prior to a process of semi-automated analysis and routine report generation for hospitals in the network. In the first phase of the Clinical Information Network, we collected data on over 65 000 admission episodes. Despite clinicians' initial unfamiliarity with routine performance reporting, we found that, as an initial focus, both engaging with each hospital and providing them information helped improve the quality of data and therefore reports. The process has involved mutual learning and building of trust in the data and should provide the basis for collaborative efforts to improve care, to understand patient outcome, and to evaluate interventions through shared learning. We have found that hospitals are willing to support the development of a clinically focused but geographically dispersed Clinical Information Network in a low-income setting. Such networks show considerable promise as platforms for collaborative efforts to improve care, to provide better information for decision making, and to enable locally relevant research.

English M, Irimu G, Agweyu A, Gathara D, Oliwa J, Ayieko P, Were F, Paton C, Tunis S, Forrest CB. 2016. Building Learning Health Systems to Accelerate Research and Improve Outcomes of Clinical Care in Low- and Middle-Income Countries. PLoS Med, 13 (4), pp. e1001991. | Show Abstract | Read more

Mike English and colleagues argue that as efforts are made towards achieving universal health coverage it is also important to build capacity to develop regionally relevant evidence to improve healthcare.

Rahimi K, Velardo C, Triantafyllidis A, Conrad N, Shah SA, Chantler T, Mohseni H, Stoppani E, Moore F, Paton C et al. 2015. A user-centred home monitoring and self-management system for patients with heart failure: a multicentre cohort study. Eur Heart J Qual Care Clin Outcomes, 1 (2), pp. 66-71. | Show Abstract | Read more

Aims: Previous generations of home monitoring systems have had limited usability. We aimed to develop and evaluate a user-centred and adaptive system for health monitoring and self-management support in patients with heart failure. Methods and results: Patients with heart failure were recruited from three UK centres and provided with Internet-enabled tablet computers that were wirelessly linked with sensor devices for blood pressure, heart rate, and weight monitoring. Patient observations, interviews, and concurrent analyses of the automatically collected data from their monitoring devices were used to increase the usability of the system. Of the 52 participants (median age 77 years, median follow-up 6 months [interquartile range, IQR, 3.6-9.2]), 24 (46%) had no, or very limited prior, experience with digital technologies. It took participants about 1.5 min to complete the daily monitoring tasks, and the rate of failed attempts in completing tasks was <5%. After 45 weeks of observation, participants still used the system on 4.5 days per week (confidence interval 3.2-5.7 days). Of the 46 patients who could complete the final survey, 93% considered the monitoring system as easy to use and 38% asked to keep the system for self-management support after the study was completed. Conclusion: We developed a user-centred home monitoring system that enabled a wide range of heart failure patients, with differing degrees of IT literacy, to monitor their health status regularly. Despite no active medical intervention, patients felt that they benefited from the reassurance and sense of connectivity that the monitoring system provided.

Tuti T, Bitok M, Paton C, Makone B, Malla L, Muinga N, Gathara D, English M. 2016. Innovating to enhance clinical data management using non-commercial and open source solutions across a multi-center network supporting inpatient pediatric care and research in Kenya. J Am Med Inform Assoc, 23 (1), pp. 184-192. | Show Abstract | Read more

OBJECTIVE: To share approaches and innovations adopted to deliver a relatively inexpensive clinical data management (CDM) framework within a low-income setting that aims to deliver quality pediatric data useful for supporting research, strengthening the information culture and informing improvement efforts in local clinical practice. MATERIALS AND METHODS: The authors implemented a CDM framework to support a Clinical Information Network (CIN) using Research Electronic Data Capture (REDCap), a noncommercial software solution designed for rapid development and deployment of electronic data capture tools. It was used for collection of standardized data from case records of multiple hospitals' pediatric wards. R, an open-source statistical language, was used for data quality enhancement, analysis, and report generation for the hospitals. RESULTS: In the first year of CIN, the authors have developed innovative solutions to support the implementation of a secure, rapid pediatric data collection system spanning 14 hospital sites with stringent data quality checks. Data have been collated on over 37 000 admission episodes, with considerable improvement in clinical documentation of admissions observed. Using meta-programming techniques in R, coupled with branching logic, randomization, data lookup, and Application Programming Interface (API) features offered by REDCap, CDM tasks were configured and automated to ensure quality data was delivered for clinical improvement and research use. CONCLUSION: A low-cost clinically focused but geographically dispersed quality CDM (Clinical Data Management) in a long-term, multi-site, and real world context can be achieved and sustained and challenges can be overcome through thoughtful design and implementation of open-source tools for handling data and supporting research.

Triantafyllidis A, Velardo C, Chantler T, Shah SA, Paton C, Khorshidi R, Tarassenko L, Rahimi K, SUPPORT-HF Investigators. 2015. A personalised mobile-based home monitoring system for heart failure: The SUPPORT-HF Study. Int J Med Inform, 84 (10), pp. 743-753. | Show Abstract | Read more

BACKGROUND: Despite their potential for improving health outcomes, mobile-based home monitoring systems for heart failure have not yet been taken up widely by the patients and providers. OBJECTIVES: To design and iteratively move towards a personalised mobile health monitoring system for patients living with heart failure, according to their health care and usability needs. METHODS: We present an iterative approach to refining a remote health monitoring system that is based on interactions between different actors (patients, clinicians, social scientists and engineers) and supports the collection of quantitative and qualitative information about user experience and engagement. Patients were provided with tablet computers and commercially available sensing devices (a blood pressure monitor, a set of weighing scales, and a pulse oximeter) in order to complete physiological measurements at home, answer symptom-specific questionnaires, review their personal readings, view educational material on heart failure self-management, and communicate with their health professionals. The system supported unobtrusive remote software upgrades via an application distribution channel and the activation or deactivation of functional components by health professionals during run-time operation. We report early findings from the application of this approach in a cohort of 26 heart failure patients (mean age 72±15 years), their caregivers and healthcare professionals who participated in the SUPPORT-HF (Seamless User-centred Proactive Provision Of Risk-stratified Treatment for Heart Failure) study over a one-year study period (mean patient follow-up duration=270±62 days). RESULTS: The approach employed in this study led to several system upgrades dealing in particular with patient requirements for better communication with the development team and personalised self-monitoring interfaces. Engagement with the system was constantly high throughout the study and during the last week of the evaluation, 23 patients (88%) used the system at least once and 16 patients (62%) at least three times. CONCLUSIONS: Designers of future mobile-based home monitoring systems for heart failure and other chronic conditions could leverage the described approach as a means of meeting patients' needs during system use within the home environment and facilitating successful uptake.

Hansen MM, Miron-Shatz T, Lau AYS, Paton C. 2014. Big Data in Science and Healthcare: A Review of Recent Literature and Perspectives. Contribution of the IMIA Social Media Working Group. Yearb Med Inform, 9 (01), pp. 21-26. | Show Abstract | Read more

OBJECTIVES: As technology continues to evolve and rise in various industries, such as healthcare, science, education, and gaming, a sophisticated concept known as Big Data is surfacing. The concept of analytics aims to understand data. We set out to portray and discuss perspectives of the evolving use of Big Data in science and healthcare and, to examine some of the opportunities and challenges. METHODS: A literature review was conducted to highlight the implications associated with the use of Big Data in scientific research and healthcare innovations, both on a large and small scale. RESULTS: Scientists and health-care providers may learn from one another when it comes to understanding the value of Big Data and analytics. Small data, derived by patients and consumers, also requires analytics to become actionable. Connectivism provides a framework for the use of Big Data and analytics in the areas of science and healthcare. This theory assists individuals to recognize and synthesize how human connections are driving the increase in data. Despite the volume and velocity of Big Data, it is truly about technology connecting humans and assisting them to construct knowledge in new ways. Concluding Thoughts: The concept of Big Data and associated analytics are to be taken seriously when approaching the use of vast volumes of both structured and unstructured data in science and health-care. Future exploration of issues surrounding data privacy, confidentiality, and education are needed. A greater focus on data from social media, the quantified self-movement, and the application of analytics to "small data" would also be useful.

Glover M, Kira A, Gentles D, Cowie N, Paton C, Moetara W. 2014. The WERO group stop smoking competition: main outcomes of a pre- and post- study. BMC Public Health, 14 (1), pp. 599. | Show Abstract | Read more

BACKGROUND: One potential promising strategy for increasing smoking cessation for Māori (Indigenous New Zealanders) and New Zealand resident Pacific Island people is Quit and Win competitions. The current uncontrolled pre and post study, WERO (WERO in Māori language means challenge), differs from previous studies in that it aims to investigate if a stop smoking contest, using both within team support, external support from a team coach and cessation experts, and technology, would be effective in prompting and sustaining quitting. METHOD: Fifteen teams, recruited from urban Māori, rural Māori and urban Pacific communities, competed to win a NZ$5000 (about € 3,000, £ 2600) prize for a charity or community group of their choice. People were eligible if they were aged 18 years and over and identified as smokers. Smoking status was biochemically validated at the start and end of the 3 month competition. At 3-months post competition self-reported smoking status was collected. RESULTS: Fourteen teams with 10 contestants and one team with eight contestants were recruited. At the end of the competition the biochemically verified quit rate was 36%. The 6 months self-reported quit rate was 26%. The Pacific and rural Māori teams had high end of competition and 6 months follow-up quit rates (46% and 44%, and 36% and 29%). CONCLUSION: WERO appeared to be successful in prompting quitting among high smoking prevalence groups. WERO combined several promising strategies for supporting cessation: peer support, cessation provider support, incentives, competition and interactive internet and mobile tools. Though designed for Māori and Pacific people, WERO could potentially be effective for other family- and community-centred cultures.

Paton C. 2014. Massive open online course for health informatics education. Healthc Inform Res, 20 (2), pp. 81-87. | Show Abstract | Read more

OBJECTIVES: This paper outlines a new method of teaching health informatics to large numbers of students from around the world through a Massive Open Online Course (MOOC). METHODS: The Health Informatics Forum is a social networking site for educating health informatics students and professionals [corrected]. It is running a MOOC for students from around the world that uses creative commons licenced content funded by the US government and developed by five US universities. The content is delivered through narrated lectures with slides that can be viewed online with discussion threads on the forum for class interactions. Students can maintain a professional profile, upload photos and files, write their own blog posts and post discussion threads on the forum. RESULTS: The Health Informatics Forum MOOC has been accessed by 11,316 unique users from 127 countries from August 2, 2012 to January 24, 2014. Most users accessed the MOOC via a desktop computer, followed by tablets and mobile devices and 55% of users were female. Over 400,000 unique users have now accessed the wider Health Informatics Forum since it was established in 2008. CONCLUSIONS: Advances in health informatics and educational technology have both created a demand for online learning material in health informatics and a solution for providing it. By using a MOOC delivered through a social networking platform it is hoped that high quality health informatics education will be able to be delivered to a large global audience of future health informaticians without cost.

Glover M, Bosman A, Wagemakers A, Kira A, Paton C, Cowie N. 2013. An innovative team-based stop smoking competition among Māori and Pacific Island smokers: rationale and method for the study and its evaluation. BMC Public Health, 13 (1), pp. 1228. | Show Abstract | Read more

BACKGROUND: Māori and Pacific Island people have significantly higher smoking rates compared to the rest of the New Zealand population. The main aim of this paper is to describe how knowledge of Indigenous people's practices and principles can be combined with proven effective smoking cessation support into a cessation intervention appropriate for Indigenous people. METHODS/DESIGN: A literature review was conducted to identify what cultural principles and practices could be used to increase salience, and what competition elements could have an impact on efficacy of smoking cessation. The identified elements were incorporated into the design of a cessation intervention. DISCUSSION: Cultural practices incorporated into the intervention include having a holistic family or group-centred focus, inter-group competitiveness, fundraising and ritual pledging. Competition elements included are social support, pharmacotherapy use, cash prize incentives and the use of a dedicated website and iPad application. A pre-test post-test will be combined with process evaluation to evaluate if the competition results in triggering mass-quitting, utilisation of pharmacotherapy and in increasing sustained smoking cessation and to get a comprehensive understanding of the way in which they contribute to the effect. The present study is the first to describe how knowledge about cultural practices and principles can be combined with proven cessation support into a smoking cessation contest. The findings from this study are promising and further more rigorous testing is warranted.

Paton C, Househ M, Malik M. 2013. The challenges of publishing on health informatics in developing countries. Appl Clin Inform, 4 (3), pp. 428-433. | Show Abstract | Read more

The Journal of Health Informatics in Developing Countries was established to meet a perceived need for Health Informaticians in developing countries to be able to share the results of their research in an affordable and easy-to-access online publication. The journal was developed using the open source platform "Open Journal System," and has now published 67 articles across 13 issues. A collaborative editorial approach has been established to address the problems of limited research budgets, difficulties with translating to English and other problems specific to authors from developing countries. The journal faces many challenges including ensuring future financial sustainability and inclusion in journal indexing systems. However, the continuing support of an international body of Associate Editors and Editorial Board Members has enabled a wide range of useful and informative health informatics research to be disseminated across the developing world.

Ahmed OH, Sullivan SJ, Schneiders AG, Anderson L, Paton C, McCrory PR. 2013. Ethical considerations in using Facebook for health care support: a case study using concussion management. PM R, 5 (4), pp. 328-334. | Show Abstract | Read more

Social networking sites (SNS) are now part of everyday life, and SNSs such as Facebook, YouTube, and Twitter are among the most accessed Web sites on the Internet. Although SNSs are primarily used for staying in touch with friends and family, they are increasingly being used for health-related purposes for a variety of conditions, including concussion awareness. As health interventions begin to be more commonly provided through SNSs (particularly Facebook), ethical issues have been raised with regard to confidentiality, privacy, and trust; these issues need to be addressed. This article outlines some of the key considerations when providing a concussion intervention through Facebook and discusses potential solutions to these issues.

Paton C, Hansen M, Fernandez-Luque L, Lau AYS. 2012. Self-Tracking, Social Media and Personal Health Records for Patient Empowered Self-Care. Contribution of the IMIA Social Media Working Group. Yearb Med Inform, 7 (01), pp. 16-24. | Show Abstract | Read more

OBJECTIVES: This paper explores the range of self-tracking devices and social media platforms used by the self-tracking community, and examines the implications of widespread adoption of these tools for scientific progress in health informatics. METHODS: A literature review was performed to investigate the use of social media and self-tracking technologies in the health sector. An environmental scan identified a range of products and services which were used to exemplify three levels of self-tracking: self-experimentation, social sharing of data and patient controlled electronic health records. RESULTS: There appears to be an increase in the use of self-tracking tools, particularly in the health and fitness sector, but also used in the management of chronic diseases. Evidence of efficacy and effectiveness is limited to date, primarily due to the health and fitness focus of current solutions as opposed to their use in disease management. CONCLUSIONS: Several key technologies are converging to produce a trend of increased personal health surveillance and monitoring, social connectedness and sharing, and integration of regional and national health information systems. These trends are enabling new applications of scientific techniques, from personal experimentation to e-epidemiology, as data gathered by individuals are aggregated and shared across increasingly connected healthcare networks. These trends also raise significant new ethical and scientific issues that will need to be addressed, both by health informatics researchers and the communities of self-trackers themselves.

Paton C, Bamidis PD, Eysenbach G, Hansen M, Cabrer M. 2011. Experience in the use of social media in medical and health education. Contribution of the IMIA Social Media Working Group. Yearb Med Inform, 6 (01), pp. 21-29. | Show Abstract | Read more

OBJECTIVES: Social media are online tools that allow collaboration and community building. Succinctly, they can be described as applications where "users add value". This paper aims to show how five educators have used social media tools in medical and health education to attempt to add value to the education they provide. METHODS: We conducted a review of the literature about the use of social media tools in medical and health education. Each of the authors reported on their use of social media in their educational projects and collaborated on a discussion of the advantages and disadvantages of this approach to delivering educational projects. RESULTS: We found little empirical evidence to support the use of social media tools in medical and health education. Social media are, however, a rapidly evolving range of tools, websites and online experiences and it is likely that the topic is too broad to draw definitive conclusions from any particular study. As practitioners in the use of social media, we have recognised how difficult it is to create evidence of effectiveness and have therefore presented only our anecdotal opinions based on our personal experiences of using social media in our educational projects. CONCLUSION: The authors feel confident in recommending that other educators use social media in their educational projects. Social media appear to have unique advantages over non-social educational tools. The learning experience appears to be enhanced by the ability of students to virtually build connections, make friends and find mentors. Creating a scientific analysis of why these connections enhance learning is difficult, but anecdotal and preliminary survey evidence appears to be positive and our experience reflects the hypothesis that learning is, at heart, a social activity.

Mabotuwana T, Warren J, Elley CR, Kennelly J, Paton C, Wai KC, Wells S. 2010. Quality indicators to measure blood pressure management over a time interval. Inform Prim Care, 18 (3), pp. 149-156. | Show Abstract | Read more

BACKGROUND: Quality indicators are an important part of the primary care landscape, but focus strongly on point-in-time measurements, such as a patient's last blood pressure (BP) measurement. There is a larger space of possible measurements, including ones that more explicitly consider management over an interval of time. OBJECTIVE: To determine the predictive abilities of five different quality indicators related to poor BP control. METHODS: Data from two New Zealand general practices was analysed on five BP control indicators for patients with diagnosed hypertension: 1) last BP high (>150/90 mmHg); 2) last BP high or no BP measurement; 3) two or more consistently high BP measurements for ≥ 90 days; 4) a high BP then lapse of >120 days in BP measurement; and 5) antihypertensive medication possession ratio (MPR) of <80%. Probability that a patient would be identified by each indicator for the nine-month evaluation period ending 31 March 2009 was computed for each indicator one quarter, two quarters and three quarters prior to this date. Associations among the five indicators for the evaluation period were also calculated. RESULTS: Positive predictive value (PPV) of indicators for the same indicator nine months later ranged from 27% (last BP high) to 64% (MPR). PPVs among the five measures with respect to the same time period ranged from 9% to 77% (median 33%). CONCLUSIONS: Modest PPVs between indicators suggest the importance of considering multiple indicators to incentivise best management across diverse aspects of BP control.

Atalag K, Kingsford D, Paton C, Warren J. 2010. Putting health record interoperability standards to work Electronic Journal of Health Informatics, 5 (1), | Show Abstract

This paper provides a snapshot of the current interoperability standards landscape and investigates how different standards are adopted in different jurisdictions. The aim is to provide useful insights for decision makers by looking from a wider angle to include political, social and business drivers rather than taking a purely technical approach. Semantic interoperability, which is a major bottleneck to achieving eHealth systemic interoperability, is dependent on terminology, content and messaging standards. In particular, the architectural aspects of content and messaging standards seem to be critical and currently the subject of many heated debates. A considerable amount of effort into international harmonisation is underway and evidence shows that it may be possible to use different standards and yet still be able to accomplish semantic interoperability. It is recommended that a careful analysis be performed to seek evidence, rather than relying on hearsay, for determining how each standard fulfils certain requirements depending on the context. An environmental scan and literature survey highlights the fact that making a good choice of standards depends on what outcomes are desired, and usually involves selection of a number of different standards to be applied together. It is to be noted that, non-technical aspects of standards, such as acceptance, feasibility of implementation or availability of expertise, are as important, and determine what is achievable. The paper concludes by presenting a number of options which include combinations of standards and also provides insights for the evaluation and selection process. © of articles is retained by authors.

Warren JR, Day KJ, Paton C, Warren DE, Mabotuwana TDS, Gu Y, Adnan M, Reedy W. 2010. Implementations of health information technologies with consumers as users: Findings from a systematic review Health Care and Informatics Review Online, 14 (3), pp. 2-28. | Show Abstract

Background: A systematic review of evaluations of innovative eHealth implementations was funded by the New Zealand Ministry of Health to inform information strategy. A key trend of interest to the Ministry was person-centered healthcare, including systems where health consumers use health information technology (IT) directly. Herein we report, analyze and reflect on the review findings with respect to such systems. Objectives: To review the nature and extent of known successes of health IT with consumers as users. Methods: Queries for evaluations of innovative eHealth implementations were submitted to MEDLINE, EMBASE, PsycINFO, CINAHL and Business Source Premier for articles appearing between 2003 and early 2009 and filtered on inclusion criteria of reporting actual implementations (i.e., use), innovativeness, evaluation (interpreted generously) and scaleability. Substitutions were made where more recent superior studies of the same or closely related projects could be found. Results: 100 of 1413 retrieved articles met the inclusion criteria; 47 of these involved consumers as users of a component of the evaluated system. Systems that provided messaging between the patient and their regular care provider met with satisfaction and good uptake. There were improved chronic disease outcomes in 11 of 15 education/self-management systems and 2 of 3 home telemonitoring systems where measurement of such outcomes was reported; a further 3 systems targeting the family members of individuals with chronic conditions as principal users all showed positive well-being outcomes for the caregivers. Conclusions: There have been a number of demonstrated instances of clear successes in both uptake and outcome for health IT interventions involving consumers as users, particularly for chronic condition management. However, compelling demonstrations (in terms of methods and sample size) remain isolated. More study is needed to assess the transferability of the demonstrated successes to greater scale, diverse contexts of deployment and to other conditions. Better keywords and more systematic reporting, particularly with respect to implementation and evaluation status, would aid similar reviews in the future.

Mabotuwana T, Warren J, Elley CR, Kennelly J, Paton C, Warren D, Chang Wai K, Wells S. 2010. Use of interval based quality indicators in blood pressure management to enhance quality of pay for performance incentives: comparison to two indicators from the Quality and Outcomes Framework. Qual Prim Care, 18 (2), pp. 93-101. | Show Abstract

BACKGROUND: Pay for performance incentives are becoming increasingly popular, but are typically based on only a single point-in-time measurement as an indicator of chronic condition management. AIMS: To determine the association between three time-interval based indicators of suboptimal blood pressure (BP) control and two point-in-time indicators from the UK Quality and Outcomes Framework (QOF): BP5 (the percentage of patients with hypertension in whom the last BP in the previous nine months was < or = 150/90) and DM12 (the percentage of patients with diabetes in whom the last BP in the previous 15 months was < or = 145/85). METHODS: We extracted classification data and BP measurements from four New Zealand general practices with 4260 to 6130 enrolled patients. Data were analysed for three indicators with respect to a nine-month evaluation period for patients with hypertension and a 15-month period for patients with diabetes: (1) two or more consistently high BP measurements spaced over > or = 90 days, (2) a high BP measurement followed by a lapse of >120 days in BP measurement and (3) no BP measurement for >180 days. RESULTS: For the four practices, 65-81% of the patients satisfied BP5 and 59-68% of patients satisfied DM12. Of the hypertension patients satisfying BP5, 31% (95% CI: 28-33%) failed at least one of the three interval based indicators; 42% (95% CI: 39-46%) of the diabetes patients satisfying DM12 failed at least one of the three interval based indicators. CONCLUSION: Considering only a point-in-time controlled BP measurement provides an incomplete view of the quality of BP management in patients with hypertension or diabetes over a period of time.

Warren J, Goodyear-Smith F, Miller D, Warren D, Paton C, Mabotuwana T, Arroll B. 2010. An integrated electronic lifestyle and mental health patient self-assessment for general practice: Design and initial field study Health Care and Informatics Review Online, 14 (4), pp. 18-25. | Show Abstract

The Case-finding and Help Assessment Tool (CHAT) is a validated self-administered lifestyle and mood assessment assessing problem drinking, smoking, other drug use, gambling, anxiety, depression, abuse, anger and physical inactivity. Herein we present development and initial acceptability assessment of an electronic version (eCHAT) for use by patients at the general practice immediately prior to consultation with their general practitioner (GP). The system is designed to allow patients to undertake the eCHAT interview using a touchscreen display and to then provide the assessment data to the GP through their Practice Management System (PMS) for follow-up discussion with the patient. After initial feedback and subsequent minor modifications in a laboratory setting, the tool was deployed consecutively to two general practices. Fifty-one consenting adult patients completed a feedback survey. In addition to the patient feedback, a focus group of GP users, developers and researchers identified further issues for refinement of the system. Initial issues included the challenge of achieving a simple and reliable user interface design for patients to identify themselves. Subsequent to modification for this, eCHAT is found to be usable and acceptable for patients in the GP setting. In response to the focus group feedback, the PMS display for use by the GP in consultation has been modified to provide summary as well as detailed information about the eCHAT results. Further research directions include a randomised controlled trial to assess the impact of eCHAT screening on overall quality-of-life, and development of Web and mobile interfaces.

Murray PJ, Cabrer M, Hansen M, Paton C, Elkin PL, Erdley WS. 2008. Towards addressing the opportunities and challenges of Web 2.0 for health and informatics. Yearb Med Inform, 17 (01), pp. 44-51. | Show Abstract | Read more

OBJECTIVE: To provide an overview of Web 2.0 and Health 2.0, and so facilitate a widespread discussion of the nature of these concepts and their possible application within the health domain, and implications for health and biomedical informatics and for IMIA. METHODS: IMIA, the International Medical Informatics Association, has established a Web 2.0 Exploratory Taskforce to bring together interested individuals from within and outside IMIA to explore the nature and potential of Web 2.0 applications. The Taskforce aims to develop background materials and sample uses of Web 2.0 applications, so as to propose specific lines of action for the IMIA Board and General Assembly. This paper provides a brief overview of Web 2.0 and related concepts, and examples of general and health-specific Web 2.0 applications. Some examples of the issues, challenges and opportunities are introduced, to set the scene for a wider dialogue on if, how, and how best, IMIA, and the wider health and informatics communities, should use these new applications and approaches. RESULTS AND CONCLUSIONS: This brief paper provides an introduction to, and overview of, the many issues involved in considering the application of Web 2.0 to health and informatics. All interested individuals and organisations are invited to use this as a starting point for engaging in wider discussion and contributing to the Taskforce and to IMIA's future.

Paton C, Al-Ubaydli M. 2006. The doctor's PDA and Smartphone handbook: medical records. J R Soc Med, 99 (4), pp. 183-184. | Read more

Al-Ubaydli M, Paton C. 2006. The Doctor's PDA and Smartphone Handbook: medical references. J R Soc Med, 99 (3), pp. 120-124. | Read more

Paton C, Al-Ubaydli M. 2006. The doctor's PDA and Smartphone Handbook: the task list. J R Soc Med, 99 (2), pp. 73-76. | Read more

Al-Ubaydli M, Paton C. 2006. The doctor's PDA and Smartphone Handbook: databases. J R Soc Med, 99 (1), pp. 20-23. | Read more

Al-Ubaydli M, Paton C. 2005. The Doctor's PDA and Smartphone Handbook. Personal digital assistant. J R Soc Med, 98 (11), pp. 494-495. | Read more

Muinga N, Magare S, Monda J, Kamau O, Houston S, Fraser H, Powell J, English M, Paton C. Implementing an Open Source Electronic Health Record System in Kenyan Health Care Facilities: Case Study (Preprint) | Show Abstract | Read more

<sec> <title>BACKGROUND</title> <p>The Kenyan government, working with international partners and local organizations, has developed an eHealth strategy, specified standards, and guidelines for electronic health record adoption in public hospitals and implemented two major health information technology projects: District Health Information Software Version 2, for collating national health care indicators and a rollout of the KenyaEMR and International Quality Care Health Management Information Systems, for managing 600 HIV clinics across the country. Following these projects, a modified version of the Open Medical Record System electronic health record was specified and developed to fulfill the clinical and administrative requirements of health care facilities operated by devolved counties in Kenya and to automate the process of collating health care indicators and entering them into the District Health Information Software Version 2 system.</p> </sec> <sec> <title>OBJECTIVE</title> <p>We aimed to present a descriptive case study of the implementation of an open source electronic health record system in public health care facilities in Kenya.</p> </sec> <sec> <title>METHODS</title> <p>We conducted a landscape review of existing literature concerning eHealth policies and electronic health record development in Kenya. Following initial discussions with the Ministry of Health, the World Health Organization, and implementing partners, we conducted a series of visits to implementing sites to conduct semistructured individual interviews and group discussions with stakeholders to produce a historical case study of the implementation.</p> </sec> <sec> <title>RESULTS</title> <p>This case study describes how consultants based in Kenya, working with developers in India and project stakeholders, implemented the new system into several public hospitals in a county in rural Kenya. The implementation process included upgrading the hospital information technology infrastructure, training users, and attempting to garner administrative and clinical buy-in for adoption of the system. The initial deployment was ultimately scaled back due to a complex mix of sociotechnical and administrative issues. Learning from these early challenges, the system is now being redesigned and prepared for deployment in 6 new counties across Kenya.</p> </sec> <sec> <title>CONCLUSIONS</title> <p>Implementing electronic health record systems is a challenging process in high-income settings. In low-income settings, such as Kenya, open source software may offer some respite from the high costs of software licensing, but the familiar challenges of clinical and administration buy-in, the need to adequately train users, and the need for the provision of ongoing technical support are common across the North-South divide. Strategies such as creating local support teams, using local development resources, ensuring end user buy-in, and rolling out in smaller facilities before larger hospitals are being incorporated into the project. These are positive developments to help maintain momentum as the project continues. Further integration with existing open source communities could help ongoing development and implementations of the project. We hope this case study will provide some lessons and guidance for other challenging implementations of electronic health record systems as they continue across Africa.</p> </sec>

Muinga N, Magare S, Monda J, English M, Fraser H, Powell J, Paton C. Survey of Electronic Health Record (EHR) Systems in Kenyan Public Hospitals: A mixed-methods survey (Preprint) | Show Abstract | Read more

<sec> <title>BACKGROUND</title> <p>As healthcare facilities in Low- and Middle-Income Countries (LMICs) such as Kenya adopt Electronic Health Record (EHR) systems to improve hospital administration and patient care, it is important to understand the adoption process, identify the key stakeholders, and assess the capabilities of the systems in use.</p> </sec> <sec> <title>OBJECTIVE</title> <p>To describe the level of adoption of Electronic Health Records systems in public hospitals and understand the process of adoption from Health Management Information System (HMIS) system vendors and system users.</p> </sec> <sec> <title>METHODS</title> <p>We conducted a survey of County Health Records Information Officers (CHRIOs) in Kenya to determine the level of adoption of Electronic Health Records systems in public hospitals. We conducted site visits to hospitals to view systems in use and to interview hospital administrators and end users. We also interviewed Health Management Information System (HMIS) system vendors to understand the adoption process from their perspective.</p> </sec> <sec> <title>RESULTS</title> <p>From the survey of CHRIOs, all facilities mentioned had adopted some form of EHR. Hospitals commonly purchased systems for patient administration and hospital billing functions. Radiology and laboratory management systems were commonly standalone systems. There were varying levels of interoperability within facilities that had more than one system in operation. We only saw one in-patient EHR system in use although many vendors and hospital administrators we interviewed were planning to adopt or support such systems. From the user perspective, issues such as system usability, adequate training, availability of adequate infrastructure and system support emerged. From the vendor perspective, a wide range of services was available to the hospital though constrained by funding and the need to computerise service areas that were deemed as priority. Additionally, vendors were unable to implement some data sharing modules linking to national HMIS due to lack of appropriate policies to facilitate this and users’ lack of confidence in new technologies such as cloud services.</p> </sec> <sec> <title>CONCLUSIONS</title> <p>EHR adoption in Kenya has been underway for some years, particularly in comprehensive care clinics, and hospitals are increasing purchasing systems to support administrative functions. Considerable support from government, donors and regional health informatics organisations will be required to enable hospitals to move to full EHR adoption for in-patient care.</p> </sec>

Muinga N, Magare S, Monda J, Kamau O, Houston S, Fraser H, Powell J, English M, Paton C. 2018. Implementing an Open Source Electronic Health Record System in Kenyan Health Care Facilities: Case Study. JMIR Med Inform, 6 (2), pp. e22. | Show Abstract | Read more

BACKGROUND: The Kenyan government, working with international partners and local organizations, has developed an eHealth strategy, specified standards, and guidelines for electronic health record adoption in public hospitals and implemented two major health information technology projects: District Health Information Software Version 2, for collating national health care indicators and a rollout of the KenyaEMR and International Quality Care Health Management Information Systems, for managing 600 HIV clinics across the country. Following these projects, a modified version of the Open Medical Record System electronic health record was specified and developed to fulfill the clinical and administrative requirements of health care facilities operated by devolved counties in Kenya and to automate the process of collating health care indicators and entering them into the District Health Information Software Version 2 system. OBJECTIVE: We aimed to present a descriptive case study of the implementation of an open source electronic health record system in public health care facilities in Kenya. METHODS: We conducted a landscape review of existing literature concerning eHealth policies and electronic health record development in Kenya. Following initial discussions with the Ministry of Health, the World Health Organization, and implementing partners, we conducted a series of visits to implementing sites to conduct semistructured individual interviews and group discussions with stakeholders to produce a historical case study of the implementation. RESULTS: This case study describes how consultants based in Kenya, working with developers in India and project stakeholders, implemented the new system into several public hospitals in a county in rural Kenya. The implementation process included upgrading the hospital information technology infrastructure, training users, and attempting to garner administrative and clinical buy-in for adoption of the system. The initial deployment was ultimately scaled back due to a complex mix of sociotechnical and administrative issues. Learning from these early challenges, the system is now being redesigned and prepared for deployment in 6 new counties across Kenya. CONCLUSIONS: Implementing electronic health record systems is a challenging process in high-income settings. In low-income settings, such as Kenya, open source software may offer some respite from the high costs of software licensing, but the familiar challenges of clinical and administration buy-in, the need to adequately train users, and the need for the provision of ongoing technical support are common across the North-South divide. Strategies such as creating local support teams, using local development resources, ensuring end user buy-in, and rolling out in smaller facilities before larger hospitals are being incorporated into the project. These are positive developments to help maintain momentum as the project continues. Further integration with existing open source communities could help ongoing development and implementations of the project. We hope this case study will provide some lessons and guidance for other challenging implementations of electronic health record systems as they continue across Africa.

Kumar P, Paton C, Kirigia D. 2016. I've got 99 problems but a phone ain't one: Electronic and mobile health in low and middle income countries. Arch Dis Child, 101 (10), pp. 974-979. | Show Abstract | Read more

Mobile technology is very prevalent in Kenya-mobile phone penetration is at 88% and mobile data subscriptions form 99% of all internet subscriptions. While there is great potential for such ubiquitous technology to revolutionise access and quality of healthcare in low-resource settings, there have been few successes at scale. Implementations of electronic health (e-Health) and mobile health (m-Health) technologies in countries like Kenya are yet to tackle human resource constraints or the political, ethical and financial considerations of such technologies. We outline recent innovations that could improve access and quality while considering the costs of healthcare. One is an attempt to create a scalable clinical decision support system by engaging a global network of specialist doctors and reversing some of the damaging effects of medical brain drain. The other efficiently extracts digital information from paper-based records using low-cost and locally produced tools such as rubber stamps to improve adherence to clinical practice guidelines. By bringing down the costs of remote consultations and clinical audit, respectively, these projects offer the potential for clinics in resource-limited settings to deliver high-quality care. This paper makes a case for continued and increased investment in social enterprises that bridge academia, public and private sectors to deliver sustainable and scalable e-Health and m-Health solutions.

English M, Irimu G, Agweyu A, Gathara D, Oliwa J, Ayieko P, Were F, Paton C, Tunis S, Forrest CB. 2016. Building Learning Health Systems to Accelerate Research and Improve Outcomes of Clinical Care in Low- and Middle-Income Countries. PLoS Med, 13 (4), pp. e1001991. | Show Abstract | Read more

Mike English and colleagues argue that as efforts are made towards achieving universal health coverage it is also important to build capacity to develop regionally relevant evidence to improve healthcare.

Tuti T, Bitok M, Paton C, Makone B, Malla L, Muinga N, Gathara D, English M. 2016. Innovating to enhance clinical data management using non-commercial and open source solutions across a multi-center network supporting inpatient pediatric care and research in Kenya. J Am Med Inform Assoc, 23 (1), pp. 184-192. | Show Abstract | Read more

OBJECTIVE: To share approaches and innovations adopted to deliver a relatively inexpensive clinical data management (CDM) framework within a low-income setting that aims to deliver quality pediatric data useful for supporting research, strengthening the information culture and informing improvement efforts in local clinical practice. MATERIALS AND METHODS: The authors implemented a CDM framework to support a Clinical Information Network (CIN) using Research Electronic Data Capture (REDCap), a noncommercial software solution designed for rapid development and deployment of electronic data capture tools. It was used for collection of standardized data from case records of multiple hospitals' pediatric wards. R, an open-source statistical language, was used for data quality enhancement, analysis, and report generation for the hospitals. RESULTS: In the first year of CIN, the authors have developed innovative solutions to support the implementation of a secure, rapid pediatric data collection system spanning 14 hospital sites with stringent data quality checks. Data have been collated on over 37 000 admission episodes, with considerable improvement in clinical documentation of admissions observed. Using meta-programming techniques in R, coupled with branching logic, randomization, data lookup, and Application Programming Interface (API) features offered by REDCap, CDM tasks were configured and automated to ensure quality data was delivered for clinical improvement and research use. CONCLUSION: A low-cost clinically focused but geographically dispersed quality CDM (Clinical Data Management) in a long-term, multi-site, and real world context can be achieved and sustained and challenges can be overcome through thoughtful design and implementation of open-source tools for handling data and supporting research.

Triantafyllidis A, Velardo C, Chantler T, Shah SA, Paton C, Khorshidi R, Tarassenko L, Rahimi K, SUPPORT-HF Investigators. 2015. A personalised mobile-based home monitoring system for heart failure: The SUPPORT-HF Study. Int J Med Inform, 84 (10), pp. 743-753. | Show Abstract | Read more

BACKGROUND: Despite their potential for improving health outcomes, mobile-based home monitoring systems for heart failure have not yet been taken up widely by the patients and providers. OBJECTIVES: To design and iteratively move towards a personalised mobile health monitoring system for patients living with heart failure, according to their health care and usability needs. METHODS: We present an iterative approach to refining a remote health monitoring system that is based on interactions between different actors (patients, clinicians, social scientists and engineers) and supports the collection of quantitative and qualitative information about user experience and engagement. Patients were provided with tablet computers and commercially available sensing devices (a blood pressure monitor, a set of weighing scales, and a pulse oximeter) in order to complete physiological measurements at home, answer symptom-specific questionnaires, review their personal readings, view educational material on heart failure self-management, and communicate with their health professionals. The system supported unobtrusive remote software upgrades via an application distribution channel and the activation or deactivation of functional components by health professionals during run-time operation. We report early findings from the application of this approach in a cohort of 26 heart failure patients (mean age 72±15 years), their caregivers and healthcare professionals who participated in the SUPPORT-HF (Seamless User-centred Proactive Provision Of Risk-stratified Treatment for Heart Failure) study over a one-year study period (mean patient follow-up duration=270±62 days). RESULTS: The approach employed in this study led to several system upgrades dealing in particular with patient requirements for better communication with the development team and personalised self-monitoring interfaces. Engagement with the system was constantly high throughout the study and during the last week of the evaluation, 23 patients (88%) used the system at least once and 16 patients (62%) at least three times. CONCLUSIONS: Designers of future mobile-based home monitoring systems for heart failure and other chronic conditions could leverage the described approach as a means of meeting patients' needs during system use within the home environment and facilitating successful uptake.

Glover M, Kira A, Gentles D, Cowie N, Paton C, Moetara W. 2014. The WERO group stop smoking competition: main outcomes of a pre- and post- study. BMC Public Health, 14 (1), pp. 599. | Show Abstract | Read more

BACKGROUND: One potential promising strategy for increasing smoking cessation for Māori (Indigenous New Zealanders) and New Zealand resident Pacific Island people is Quit and Win competitions. The current uncontrolled pre and post study, WERO (WERO in Māori language means challenge), differs from previous studies in that it aims to investigate if a stop smoking contest, using both within team support, external support from a team coach and cessation experts, and technology, would be effective in prompting and sustaining quitting. METHOD: Fifteen teams, recruited from urban Māori, rural Māori and urban Pacific communities, competed to win a NZ$5000 (about € 3,000, £ 2600) prize for a charity or community group of their choice. People were eligible if they were aged 18 years and over and identified as smokers. Smoking status was biochemically validated at the start and end of the 3 month competition. At 3-months post competition self-reported smoking status was collected. RESULTS: Fourteen teams with 10 contestants and one team with eight contestants were recruited. At the end of the competition the biochemically verified quit rate was 36%. The 6 months self-reported quit rate was 26%. The Pacific and rural Māori teams had high end of competition and 6 months follow-up quit rates (46% and 44%, and 36% and 29%). CONCLUSION: WERO appeared to be successful in prompting quitting among high smoking prevalence groups. WERO combined several promising strategies for supporting cessation: peer support, cessation provider support, incentives, competition and interactive internet and mobile tools. Though designed for Māori and Pacific people, WERO could potentially be effective for other family- and community-centred cultures.

Paton C, Hansen M, Fernandez-Luque L, Lau AYS. 2012. Self-Tracking, Social Media and Personal Health Records for Patient Empowered Self-Care. Contribution of the IMIA Social Media Working Group. Yearb Med Inform, 7 (01), pp. 16-24. | Show Abstract | Read more

OBJECTIVES: This paper explores the range of self-tracking devices and social media platforms used by the self-tracking community, and examines the implications of widespread adoption of these tools for scientific progress in health informatics. METHODS: A literature review was performed to investigate the use of social media and self-tracking technologies in the health sector. An environmental scan identified a range of products and services which were used to exemplify three levels of self-tracking: self-experimentation, social sharing of data and patient controlled electronic health records. RESULTS: There appears to be an increase in the use of self-tracking tools, particularly in the health and fitness sector, but also used in the management of chronic diseases. Evidence of efficacy and effectiveness is limited to date, primarily due to the health and fitness focus of current solutions as opposed to their use in disease management. CONCLUSIONS: Several key technologies are converging to produce a trend of increased personal health surveillance and monitoring, social connectedness and sharing, and integration of regional and national health information systems. These trends are enabling new applications of scientific techniques, from personal experimentation to e-epidemiology, as data gathered by individuals are aggregated and shared across increasingly connected healthcare networks. These trends also raise significant new ethical and scientific issues that will need to be addressed, both by health informatics researchers and the communities of self-trackers themselves.

Atalag K, Kingsford D, Paton C, Warren J. 2010. Putting health record interoperability standards to work Electronic Journal of Health Informatics, 5 (1), | Show Abstract

This paper provides a snapshot of the current interoperability standards landscape and investigates how different standards are adopted in different jurisdictions. The aim is to provide useful insights for decision makers by looking from a wider angle to include political, social and business drivers rather than taking a purely technical approach. Semantic interoperability, which is a major bottleneck to achieving eHealth systemic interoperability, is dependent on terminology, content and messaging standards. In particular, the architectural aspects of content and messaging standards seem to be critical and currently the subject of many heated debates. A considerable amount of effort into international harmonisation is underway and evidence shows that it may be possible to use different standards and yet still be able to accomplish semantic interoperability. It is recommended that a careful analysis be performed to seek evidence, rather than relying on hearsay, for determining how each standard fulfils certain requirements depending on the context. An environmental scan and literature survey highlights the fact that making a good choice of standards depends on what outcomes are desired, and usually involves selection of a number of different standards to be applied together. It is to be noted that, non-technical aspects of standards, such as acceptance, feasibility of implementation or availability of expertise, are as important, and determine what is achievable. The paper concludes by presenting a number of options which include combinations of standards and also provides insights for the evaluation and selection process. © of articles is retained by authors.

Mabotuwana T, Warren J, Elley CR, Kennelly J, Paton C, Warren D, Chang Wai K, Wells S. 2010. Use of interval based quality indicators in blood pressure management to enhance quality of pay for performance incentives: comparison to two indicators from the Quality and Outcomes Framework. Qual Prim Care, 18 (2), pp. 93-101. | Show Abstract

BACKGROUND: Pay for performance incentives are becoming increasingly popular, but are typically based on only a single point-in-time measurement as an indicator of chronic condition management. AIMS: To determine the association between three time-interval based indicators of suboptimal blood pressure (BP) control and two point-in-time indicators from the UK Quality and Outcomes Framework (QOF): BP5 (the percentage of patients with hypertension in whom the last BP in the previous nine months was < or = 150/90) and DM12 (the percentage of patients with diabetes in whom the last BP in the previous 15 months was < or = 145/85). METHODS: We extracted classification data and BP measurements from four New Zealand general practices with 4260 to 6130 enrolled patients. Data were analysed for three indicators with respect to a nine-month evaluation period for patients with hypertension and a 15-month period for patients with diabetes: (1) two or more consistently high BP measurements spaced over > or = 90 days, (2) a high BP measurement followed by a lapse of >120 days in BP measurement and (3) no BP measurement for >180 days. RESULTS: For the four practices, 65-81% of the patients satisfied BP5 and 59-68% of patients satisfied DM12. Of the hypertension patients satisfying BP5, 31% (95% CI: 28-33%) failed at least one of the three interval based indicators; 42% (95% CI: 39-46%) of the diabetes patients satisfying DM12 failed at least one of the three interval based indicators. CONCLUSION: Considering only a point-in-time controlled BP measurement provides an incomplete view of the quality of BP management in patients with hypertension or diabetes over a period of time.

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