Application of the research electronic data capture (REDCap) system in a low- and middle income country– experiences, lessons, and challenges

The challenges of reliably collecting, storing, organizing, and analyzing research data are critical in low- and middle-income countries (LMICs), particularly in Sub-Saharan Africa where several healthcare and biomedical research organizations have limited data infrastructure. The Research Electronic Data Capture (REDCap) System has been widely used by many institutions and hospitals in the USA for data collection, entry, and management and could help solve this problem. This study reports on the experiences, challenges, and lessons learned from establishing and applying REDCap for a large US-Nigeria research partnership that includes two sites in Nigeria, (the College of Medicine of the University of Lagos (CMUL) and Jos University Teaching Hospital (JUTH)) and Northwestern University (NU) in Chicago, Illinois in the United States. The largest challenges to this implementation were significant technical obstacles: the lack of REDCap-trained personnel, transient electrical power supply, and slow/ intermittent internet connectivity. However, asynchronous communication and on-site hands-on collaboration between the Nigerian sites and NU led to the successful installation and configuration of REDCap to meet the needs of the Nigerian sites. An example of one lesson learned is the use of Virtual Private Network (VPN) as a solution to poor internet connectivity at one of the sites, and its adoption is underway at the other. Virtual Private Servers (VPS) or shared online hosting were also evaluated and offer alternative solutions. Installing and using REDCap in LMIC institutions for research data management is feasible; however, planning for trained personnel and addressing electrical and internet infrastructural requirements are essential to optimize its use. Building this fundamental research capacity within LMICs across Africa could substantially enhance the potential for more cross-institutional and cross-country collaboration in future research endeavors.

We Asked the Experts: The Promises and Challenges of Surgical Telehealth in Low Resourced Settings

Access to safe and timely surgical care saves lives, but its multiple barriers in low- and middle-income countries (LMICs) contribute to high postoperative mortality [1]. In these settings, surgical health systems are fragile due to a shortage of supplies such as drugs, anesthesia equipment and oxygen, the maldistribution of surgical specialists, poor referral systems, and an inability to routinely track processes and outcomes indicators for quality improvement. The ongoing Covid-19 pandemic has heightened barriers to surgical care in LMICs with resultant increases in unmet surgical needs. On the other hand, the pandemic has revealed the great potentials of telehealth.

Telehealth, which is the provision of healthcare-related services over a distance using electronic and telecommunication technologies, has created solutions to leapfrog certain barriers to surgical care in LMICs. Long distance travel to reach facilities and extended waiting times to see specialists can be circumvented by phone and online consultations. These virtual visits are not only cost saving but can prevent critical delays in patient care. Remote consultations can take on various forms. Firstly, initial visits and preoperative instructions can be done through telehealth platforms from the comfort of patient homes. In certain low acuity and elective cases, video visits may make it possible to determine the need for an operation or the need for in-person visitation to assist surgical planning. Additionally, mobile apps, direct phone calls, and instant messaging are suitable for preoperative education and assisting patients in navigating barriers to surgical access in addition to using video chat platforms. Likewise, mHealth apps and real-time video features allow for postoperative follow-up including routine wound inspection and utilize community health workers, nurses, or general medical doctors located closer to the patient than the hospital that provided the surgical care. The addition of artificial intelligence technology to mHealth could aid these cadres to identify wound infections. In Rwanda, machine learning is being harnessed to detect postoperative wound infections in rural women after Cesarean sections [2]. Finally, outreach by surgeons to rural areas can be strengthened by remote preoperative consultations to identify appropriate operative candidates, provide virtual spaces for planning with local teams, and conduct postoperative follow-up. Therefore, telehealth maximizes the impact of visiting specialists and improves the quality of patient care.

Poor communication and referral networks between health facilities are major barriers to timely and quality access to surgical care in LMICs. Telehealth allows doctors and nurses in rural and primary care facilities to communicate quickly with surgeons at regional and tertiary hospitals. The mHealth app, Vula Mobile, is used ubiquitously by South African rural doctors and nurses to refer persons with surgical conditions to specialists at higher level hospitals. A 2019 study showed that one-third of acute orthopedic conditions were managed on this platform through expert advice without the need for transfer [3]. The median response time on the app was less than 30 minutes. In addition, metadata from mHealth referral apps can be used to track volumes, referral times, and patient flow, which might be used for quality improvement efforts. This type of telehealth platform shows promise and might be scaled-up in other LMICs to better link networks of non-specialist health care providers and surgeons.

If higher bandwidth is available, real-time video platforms, which allow for in-depth consultations and case discussions, can be used to overcome specialist shortages in LMICs. Virtual multi-disciplinary conferences are being used in South–South and North–South collaborations. For example, the Global Cancer Institute has a network of over 500 doctors from Africa, Asia, and Latin America who present cancer cases for discussion with US oncology experts [4].

The limited case mix at some LMIC training hospitals and the shortage of surgical subspecialists can impede the acquisition of certain operative skills. Telesurgery, or intra-operative tele-mentoring, is where a senior surgeon located remotely can give immediate and continuous feedback to the operating surgeon. Early attempts at South–South telesurgery collaborations have shown good patient outcomes [5].

Another telehealth innovation for skills acquisition is simulation, or the use of models to imitate the steps of an operation. Simulators can be high-fidelity units with computer animation or low-fidelity models made from inexpensive materials like cardboard boxes and graspers to learn three-dimensional techniques such as laparoscopic suturing and knot tying. Simulation has been shown to be particularly useful during the Covid-19 pandemic to augment training since elective operative volume has decreased in almost every country worldwide…

The revival of telemedicine in the age of COVID-19: Benefits and impediments for Pakistan

Dear Editor

Defined as “the use of information and telecommunication technologies (ICT) in medicine, telemedicine intends to provide appropriate healthcare at a distance, hence eliminating the need for direct contact between a patient and physician [1]. It can be classified according to the type of interaction (pre-recorded or real-time) and type of format in which information is conveyed (videos, pictures, audio, etc.) [2]. Particularly in the setting of a natural or man-made disaster, telemedicine is known to function as a key component in the emergency response, enabling people to access routine care and health support despite widespread disruptions in health services [3].

The relevance of telemedicine to our health systems is more evident than ever today as we continue to battle the COVID- 19 pandemic that has modified our lifestyle and approach to medical care. In the face of lockdowns and social distancing protocols, telemedicine technologies are being employed for online consultations, monitoring and evaluating symptoms, tracking and circumventing COVID-19 hotspots, and addressing individual concerns through chat bots [4].

Although the age of COVID-19 has significantly propelled the adoption of telemedicine services globally, its market was booming even prior to the onset of the COVID-19 pandemic, with a market size estimated around US$50 billion as of 2019, projected to increase over 9-fold in the coming decade [5]. A growing body of literature supports the role of telemedicine in providing timely, affordable, and premium quality healthcare services surpassing geographical barriers, which is especially advantageous for resource limited countries. However, while it is being integrated in the health infrastructure in USA, Europe and South East Asia with increasing momentum, its future in the developing world remains obscure [6].

Although the rate is considerably slower than developed countries, developing countries are gradually adapting to the changing times with efforts to make high-quality healthcare accessible to the masses from the comfort of their residence via digital interventions. Sub-Saharan Africa, for example, has reported a significant increase in mobile health technology [7]. The implementation of telemedicine amid a concomitant burden of communicable and non-communicable diseases in low and middle income countries (LMICs) can have consequential impacts in addressing the basic health needs of the population. By reducing travel costs and time, telemedicine enables rural and marginalized communities to access the same quality of medical resources and care as urban dwellers, and promotes health equity [6].

The potential use of digital health technologies in the African context: a systematic review of evidence from Ethiopia

The World Health Organization (WHO) recently put forth a Global Strategy on Digital Health 2020–2025 with several countries having already achieved key milestones. We aimed to understand whether and how digital health technologies (DHTs) are absorbed in Africa, tracking Ethiopia as a key node. We conducted a systematic review, searching PubMed-MEDLINE, Embase, ScienceDirect, African Journals Online, Cochrane Central Registry of Controlled Trials, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform databases from inception to 02 February 2021 for studies of any design that investigated the potential of DHTs in clinical or public health practices in Ethiopia. This review was registered with PROSPERO (CRD42021240645) and it was designed to inform our ongoing DHT-enabled randomized controlled trial (RCT) (ClinicalTrials.gov ID: NCT04216420). We found 27,493 potentially relevant citations, among which 52 studies met the inclusion criteria, comprising a total of 596,128 patients, healthy individuals, and healthcare professionals. The studies involved six DHTs: mHealth (29 studies, 574,649 participants); electronic health records (13 studies, 4534 participants); telemedicine (4 studies, 465 participants); cloud-based application (2 studies, 2382 participants); information communication technology (3 studies, 681 participants), and artificial intelligence (1 study, 13,417 participants). The studies targeted six health conditions: maternal and child health (15), infectious diseases (14), non-communicable diseases (3), dermatitis (1), surgery (4), and general health conditions (15). The outcomes of interest were feasibility, usability, willingness or readiness, effectiveness, quality improvement, and knowledge or attitude toward DHTs. Five studies involved RCTs. The analysis showed that although DHTs are a relatively recent phenomenon in Ethiopia, their potential harnessing clinical and public health practices are highly visible. Their adoption and implementation in full capacity require more training, access to better devices such as smartphones, and infrastructure. DHTs hold much promise tackling major clinical and public health backlogs and strengthening the healthcare ecosystem in Ethiopia. More RCTs are needed on emerging DHTs including artificial intelligence, big data, cloud, cybersecurity, telemedicine, and wearable devices to provide robust evidence of their potential use in such settings and to materialize the WHO’s Global Strategy on Digital Health.