A series of three perspectives from the Patient Pathways and Pandemics Community of Practice on the ‘NCD Care’ app with PharmAccess in Ghana.
Click below to view the other articles:

1. Pivoting COVID-19 innovations to UHC: Is 2022 a year digital health moves up a gear?
2. Could digital platforms enhance clinicians’ health coaching skills? Reflections on technology-powered NCD services following the COVID-19 pandemic
3. A world of possibilities: How should digital health companies partner with healthcare payers to support scale-up?

What will the ‘new normal’ for healthcare delivery look like in low and middle income countries following the COVID-19 pandemic? Many health leaders are currently asking themselves this question, and very often the answer involves a lot more use of technology – much of which was introduced during the crisis but now appears to be here to stay.

Without the same urgency in this new phase of the pandemic, health systems will have more time and resources to plan their digital health adoptions more carefully, and one perspective that will be much more important this time around is that of clinicians. As the primary users of many types of digital health tools, it is vital that doctors, nurses and other health workers experience them as supportive and additive to their work rather than an additional burden. Yet skepticism and resistance to their adoption among front-line clinicians is common, and often with good reason when studies from high-income systems suggest physicians are having to spend more and more time looking at an electronic medical record rather than the patient in front of them.

It was for this reason that when pivoting their CovidConnect app in Ghana towards NCD patient management, PharmAccess were particularly keen to explore the clinical engagement side of the initiative compared to the rapid rollout of the app’s COVID-19 cousin. In particular, their hope is to create a system that doesn’t just ‘not get in the way’ of diabetes and hypertension care being delivered by providers, but actively supports clinicians to improve their health coaching and behavioral change skills with patients – whether interacting in person or online.

For all the well-documented barriers, limitations and challenges of digital healthcare delivery in low and middle income countries, discussions with a group of JLN member country practitioners and technical facilitators as part of the Patient Pathways During Pandemics series highlighted four important advantages to focus on during the development stage:

1. Compared to the paper-based or relatively basic EMR systems often found in low and middle income health systems, there is the potential for NCD-focused health platforms to build up a much more holistic picture of patients, drawing together a wider range of indicators and presenting clinicians with the most relevant information (or prompts personalized to that patient). This is especially the case for multi-sided platforms like NCD Care where both the clinician and patient can log information into their record.
2. While clinicians rarely get useful or timely feedback on the effectiveness of their health coaching or behavioral change advice in face to face care, digital platforms may offer the ability to track whether interventions and advice are working or not. Asking patients simple questions through the platform to gauge their levels of knowledge, confidence and skills to self-care – and tracking these over time – could better equip clinicians with the data they need to improve. Questions could be aggregated into a composite score, as with the Patient Activation Measure (PAM), which is widely used in chronic care research and has a strong evidence base showing lower costs of care as the PAM score improves.
3. Digital interactions between patients and clinicians (whether over voice, chat or other means) are more easily supervised for the purposes of constructive feedback and quality improvement. Many emerging market digital health providers are using their platforms to enhance clinical skills. For example, Altibbi, a digital health platform in several Middle Eastern markets, employs dedicated senior clinicians to listen into a sample of telehealth consultation calls being given by doctors on the platform and provide feedback to them on improvements to their practice to consider.
4. Digital platforms have the capability to prompt particular actions or suggestions for clinicians in real-time, whether immediately before, during or after a clinical interaction. This offers a new model of skills development that is much more immediate than episodic training away from their normal work. Though as many digital platforms have found, a ‘less is more’ approach is required so as to avoid ‘alert fatigue’.

Capitalizing on these advantages is a major challenge, but one in which several key lessons emerged from discussions about the practicalities of building soft skills development into the foundations of any digital health platform.

First was to involve the end-users from the very first stages of the development process, and ensure that the resulting interface is extremely easy to use, fits around the existing clinical workflow and makes data entry as quick as possible, whether through drop-down menus or voice-to-text.

Second was to take the time to understand the fundamental needs of patients and clinicians who will be using the tool. This includes not just the direct operational tasks that they say it needs to perform but their underlying desires and frustrations, whether that is for patients (or other clinicians) who listen to what they have to say and take it on board, or on the patient side for advice that is reliable, achievable and affordable.

Third was to build any training required around a well thought through and culturally relevant framework for which types of soft skills most need improving. Comprehensive frameworks and training packages of soft skills for clinicians do exist, but in most systems where soft skills have not been extensively developed in clinicians a simpler philosophy is more effective, such as the 5 A’s (Ask, Agree, Assess, Assist and Arrange) or other motivational techniques.

With thanks to Jonty Roland, Niti Pall, Colette Van Montfort, Alex Attachey, GV Ramana Rao, Dharmesh Lal, Javan Waita, Kasarachi Omitiran, Jake Mendales, Esteban Bermudez