ISO/TR 19231:2014

TECHNICAL ISO/TR
REPORT 19231
First edition
2014-11-15
Health informatics — Survey of
mHealth projects in low and middle
income countries (LMIC)
Informatique de santé — Étude de projets de santé mobile dans les
pays à revenu bas et moyen
Reference number
ISO/TR 19231:2014(E)
©
ISO 2014

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ISO/TR 19231:2014(E)

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ISO/TR 19231:2014(E)

Contents Page
Foreword .iv
Introduction .v
1 Scope . 1
2 Normative references . 1
3 Terms and definitions . 1
4 Symbols and abbreviated terms . 2
5 mHealth survey around the world . 3
5.1 Africa. 3
5.2 Asia . 4
5.3 South America . 6
6 mHealth use cases in LMIC . 7
6.1 Education and awareness . 7
6.2 Remote data collection . 7
6.3 Remote monitoring . 8
6.4 Communication and training for healthcare workers . 8
6.5 Disease and epidemic outbreak tracking . 8
6.6 Diagnostics and treatment support . 9
6.7 Sharing a medical image annotated with a region of interest . 9
7 Interoperable mHealth frameworks survey for LMIC . 9
7.1 ISO 14639 (all parts). 9
7.2 SA (Standards Australia) Handbook 137, 138 .10
7.3 HL7 Services-Aware Interoperability Framework (SAIF).11
7.4 HISA (Health Informatics Service Architecture) ISO 12967 .11
Bibliography .13
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ISO/TR 19231:2014(E)

Foreword
ISO (the International Organization for Standardization) is a worldwide federation of national standards
bodies (ISO member bodies). The work of preparing International Standards is normally carried out
through ISO technical committees. Each member body interested in a subject for which a technical
committee has been established has the right to be represented on that committee. International
organizations, governmental and non-governmental, in liaison with ISO, also take part in the work.
ISO collaborates closely with the International Electrotechnical Commission (IEC) on all matters of
electrotechnical standardization.
The procedures used to develop this document and those intended for its further maintenance are
described in the ISO/IEC Directives, Part 1. In particular the different approval criteria needed for the
different types of ISO documents should be noted. This document was drafted in accordance with the
editorial rules of the ISO/IEC Directives, Part 2 (see www.iso.org/directives).
Attention is drawn to the possibility that some of the elements of this document may be the subject of
patent rights. ISO shall not be held responsible for identifying any or all such patent rights. Details of any
patent rights identified during the development of the document will be in the Introduction and/or on
the ISO list of patent declarations received (see www.iso.org/patents).
Any trade name used in this document is information given for the convenience of users and does not
constitute an endorsement.
For an explanation on the meaning of ISO specific terms and expressions related to conformity
assessment, as well as information about ISO’s adherence to the WTO principles in the Technical Barriers
to Trade (TBT), see the following URL: Foreword — Supplementary information.
The committee responsible for this document is ISO/TC 215, Health Informatics.
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Introduction
Mobile Health (mHealth) is a hot topic in the health information technology (IT) industry because it can
make a big difference in healthcare services. The United Nations (UN) and World Health Organization
(WHO) are interested in mHealth technology to help overcome the current low quality healthcare
services in low and middle income countries (LMIC).
The UN describes use cases that are applicable to mHealth in LMIC: Education and Awareness; Remote
Data Collection; Remote Monitoring; Communication and Training for Healthcare Workers; Disease and
Epidemic Outbreak Tracking; and Diagnostics and Treatment Support. WHO also describes use cases:
Health call centres/Healthcare telephone help line; Emergency toll-free telephone services; Treatment
compliance; Appointment reminders; Community mobilization and health promotion; Raising
awareness; Mobile telemedicine; Public health emergencies; Health surveys and surveillance; Patient
monitoring; Information Initiatives; Decision support systems; and Patient records. For more use cases,
see References [1] and [2].
There are several eHealth frameworks already developed by a number of organizations such as
Health Level Seven (HL7), ISO/TC215, CEN/TC251, and Standards Australia (SA). Before suggesting
an interoperable mHealth framework, currently available eHealth frameworks are surveyed and
investigated to recognize how suitable each eHealth framework is for mHealth.
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TECHNICAL REPORT ISO/TR 19231:2014(E)
Health informatics — Survey of mHealth projects in low
and middle income countries (LMIC)
1 Scope
This Technical Report surveys ongoing national mHealth projects in LMIC, to which some emerging
technologies such as zero configuration and proximity computing are applicable, especially when the
information and communication technology (ICT) infrastructure is not established in those countries.
The scope is constrained to mHealth use cases and technologies for information and communication
infrastructures that are useful for LMICs. In addition, the purpose of this Technical Report is to survey
not only national mHealth projects in LMICs, but also possible mHealth frameworks that might be used.
2 Normative references
There are no normative references in this document.
3 Terms and definitions
For the purposes of this document, the following terms and definitions apply.
3.1
clinician
health professional who delivers health services directly to a patient/client
3.2
patient
individual person that is a subject of care
3.3
HIV/AIDS
human immunodeficiency virus infection
acquired immunodeficiency syndrome
disease of the human immune immunodeficiency virus
3.4
SIM card
subscriber identity module
subscriber identification module
(SIM)
integrated circuit that securely stores the international mobile subscriber identity (IMSI) and the
related key used to identify and authenticate subscribers on mobile telephony devices (such as mobile
phones and computers)
3.5
infrastructure
basic physical and organizational structures needed for the operation of a society or enterprise, or the
services and facilities necessary for an economy to function
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3.6
confidentiality
property that information is not made available or disclosed to unauthorised individuals, entities, or
processes
[SOURCE: ISO 7498-2:1989]
3.7
standard
document, established by consensus and approved by a recognised body that provides, for common and
repeated use, rules, guidelines or characteristics for activities or their results, aimed at achievement of
the optimum degree of order in a given context
[SOURCE: ISO/IEC Guide 2:2004]
3.8
solution
successful resolution to a medical problem
3.9
service
ability of a system to provide a set of output information based on a defined set of input information
[SOURCE: ISO 12967-1:2009]
3.10
healthcare
activities, services, or supplies related to the health of an individual
3.11
healthcare worker
healthcare professional involved in the direct provision of healthcare
3.12
organization
unique framework of authority within which a person or persons act, or are designated to act,
towards some purpose
[SOURCE: ISO 6523-1:1998]
3.13
subject of care
person scheduled to receive, receiving, or having healthcare
[SOURCE: ISO/EN 13606-1:2008]
3.14
use case
textual and graphical depiction of the actors and operations that address information exchange in the
context of a set of specific tasks performed by different systems or devices
4 Symbols and abbreviated terms
mHealth Mobile Health
LMIC Low and Middle Income Countries
SMS Short Message Services
PDA Personal Digital Assistant
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UHI Universal Health Identifier Service
NASH National Authentication Service for Health
NPC National Product Catalogue
CADA Chinese Aged Diabetic Assistant
AESSIMS Acute Encephalitis Syndrome Surveillance Information System
SARS Severe Acute Respiratory Syndrome
TCD Trinity College Dublin
ATNF Apollo Telemedicine Networking Foundation
5 mHealth survey around the world
Mobile devices have been reaching more people in many developing countries than power grids, road
systems, water works, or fibre optic networks. Mobile services offer a way for the public and private
sectors to reach these communities, and one of the most important spheres for this interactive contact
[3]
is health. As a result, this report survey mHealth projects which are conducted nationwide around the
world. Furthermore, several use cases of mHealth are illustrated in the next chapter in order to classify
the possible mHealth services.
5.1 Africa
5.1.1 Project: Masiluleke
Country: South Africa
Participants: Pop! Tech Accelerator, Parakeet Foundation, iTeach, frog design, MTN, Nokia-Siemens
Networks, National AIDS Helpline, National Geographic Society, Ghetto Ruff Records, Children of South
African Legacies, Aricent
Application Area: Education and Awareness
Description: Project Masiluleke was proposed and this project is in progress to harness the power of
mobile technology as a high-impact, low-cost tool in the fight against HIV/AIDS. The project provides
a suite of interventions targeting the entire HIV/AIDS care continuum under the guidance of an
international, multidisciplinary team. The project contributes to HIV/AIDS care by promoting testing,
treatment connection/adherence, and, ultimately, improved access to testing through an innovative
home HIV test kit supported by mobile counselling. Project Masiluleke is encouraging people who are
scheduled to be tested and treated for HIV/AIDS in South Africa by sending one million text messages
per day. Capitalizing on the ubiquity of mobile devices in even the most resource constrained areas
makes the potential for this project to revolutionize the public health response to HIV/AIDS in South
Africa and other parts of the globe. The model is designed for scale and replication and can be modified
to address a variety of public health and social challenges. Local languages are used for these messages
and messages are used to direct recipients to the National AIDS Helpline. Representatives of the hotline
provide information about testing services and locations when patients call.
5.1.2 Project: The Dokoza system
Country: South Africa
Participant: Dokoza, State Information Technology Agency (SITA), Centre for Public Service Innovation
(CPSI), Centre for Scientific and Industrial Research (CSIR) and the Meraka Institute, with the cooperation
of South Africa’s National Department of Health
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Application Area: Remote Data Collection
Description: The goal of Dokoza system in South Africa is to provide solutions for integrating mobile
data collection with existing health information systems which is essential for advancing patient
care. In other words, this solution is SMS-based mobile system designed to fast-track and it improves
critical services to HIV/AIDS and TB (tuberculosis) patients. In this solution, SIM cards, which can be
used across the networks, interact with a more complex back-end system that integrates with existing
hospital information systems. Integrating with existing infrastructure offers the possibility of dramatic
improvements to existing patient health information records. Also, in the 2004 pilot, both doctors and
patients found the system to be user-friendly. During the pilot test, some problems have been detected
including the duplication of data entry in instances where paper-based systems already exist and staff
shortages which hampered information collection. Despite the availability of this technology, there are
little new data on its impact until the end of the pilot.
5.1.3 Project: Mobile HIV/AIDS Support
Country: Uganda
Participant: Trinity College Dublin
Application Area: Communication and Training for Healthcare Workers
Description: In the developing world, ‘training the trainers’ (providing healthcare workers in the field
with accessible and reliable medical information) is essential for improved health service delivery. To
explore the potential advantages of using PDAs in HIV/AIDS care and treatment, Trinity College Dublin
(TCD) is collaborating with the medical school at Maker ere Hospital in Kampala, Uganda. The aim of
this project is providing high-quality medical information and advising healthcare workers in Uganda
and throughout sub-Saharan Africa. The project leaders (a group of academic clinicians from TCD, the
Dublin Institute of Technology, and North American universities) developed a prototype of a training
program on the clinical care, research, and prevention of HIV/AIDS, after an initial needs assessment.
By selecting a group of healthcare workers in the field, this program was scheduled to be evaluated,
however, testing and evaluation results have not yet been published.
5.1.4 Project: Cell Phone Apps for Clinical Diagnostic Therapeutic and Public Health Use by
Front Line Healthcare Workers
Country: Mozambique
Participant: Microsoft Research and Department of Information Systems, University of Melbourne
Application Area: Diagnostics and Treatment Support
Description: Mozambique has extensive cellular network coverage and a high percentage of health
workers who own mobile phones although this country is one of the world’s poorest. Microsoft Research
supports this project which aims to take advantage of Mozambique’s ‘wired’ reality. A suite of applications
that can run on standard mobile phones have been created by the project principals, researchers from the
University of Melbourne. Mozambican health workers use this application and get services with diagnostic
and analytical tools, including reference material in the phone’s memory, a calculator for determining drug
dosage, and a program for analysing inputs from medical sensors (e.g. low-cost pulse oximetry probes or
a simple electrocardiogram). The project duration was from March 2008 to March 2009 and researchers
concluded project result by evaluating the impact and efficacy of the applications suite.
5.2 Asia
5.2.1 Project: Chinese Aged Diabetic Assistant (CADA)
Country: China
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Participant: Microsoft Research, researchers from St Louis University, Old Dominion University, Beijing
Medical University and Peking University First Hospital
Application Area: Remote Monitoring
Description: Diabetes is becoming an important issue for developed countries such as China because
of economic developments and the resultant lifestyle. To deal with this problem, ‘Smartphone-based
self-management and support system for elderly diabetics in China’ project is in progress by Microsoft
Research and a group of researchers from several universities and Chinese medical centres. This
project provides several functions such as sending elderly diabetics recommendations and guidelines
related to physical activity, glucose and blood pressure monitoring, weight measurement, and diet
with smartphone. The product gathers and sends data on glucose levels and it is helpful for doctors by
tracking patient data and graphically displaying data for patients. The system has been implemented by
the user-centred design approach to develop software that improves the preferences and capabilities of
the targeted population to achieve maximum usability. This software has been provided free of charge
on PDAs and smart phones that run the Windows Mobile operating system.
5.2.2 Project: HealthLine
Country: Pakistan
Participant: Microsoft Research, Carnegie Melon University (CMU), Aga Khan University (Karachi) and
Health and Nutrition Development Society (HANDS)—a Pakistani NGO
Application Area: Communication and Training for Healthcare Workers
Description: To provide mHealth solutions, sufficient literacy should be guaranteed. Low and middle
income countries such as Pakistan don’t have a high literacy rate; therefore, Microsoft and others are
developing HealthLine, a speech recognition-based information system based on Microsoft Speech
Server2007 beta software. This program supports both landline access and mobile phone access. Callers
meet their needs by specifying a topic (or disease) and searching a set of menus until they reach the
required information. This information is then provided by pre-recorded message, using their local
language. In mid-2007, a test of HealthLine was performed by a group of low-literate maternal and child
health community health workers in Pakistan. The test has continued in the field while improving the
program through the addition of new features, functionality, and enhancements.
5.2.3 Project: The Acute Encephalitis Syndrome Surveillance Information System (AESSIMS)
Country: India
Participant: Voxiva, Program for Appropriate Technology in Health (PATH) and the Government of
Andhra Pradesh
Application Area: Disease and Epidemic Outbreak Tracking
Description: Every year, over two million children die from preventable diseases and over three million
children are left impaired in the developing world. Japanese Encephalitis is one of the reasons for this
tragedy, which is a devastating mosquito-borne illness. This illness can be prevented by a vaccination,
but it is not always provided due to its high cost and a lack of awareness on the disease’s true prevalence
and impact. To solve this problem, the Government of Andhra Pradesh, where the disease is endemic,
performed a pilot test of an Acute Encephalitis Syndrome Surveillance Information Management System
(AESSIMS) in one of its districts. Local health providers and clinicians reported incidences of the disease
to the AESSIMS system by using mobile phones (or web-based technologies). This service also helped
decision makers access and analyse data in real time through a variety of tools which include GIS-based
maps. It was predicted that if the pilot test were a success, the AESSIMS system can be applied across
India and into other Asian countries.
5.2.4 Project: Ericsson and Apollo Hospitals Initiative
Country: India
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Participant: Voxiva
Application Area: Diagnostics and Treatment Support
Description: In the summer of 2008, Ericsson and Apollo Telemedicine Networking Foundation (ATNF)
began a project in India, “Memorandum of Understanding to implement telemedicine applications over
broadband-enabled mobile networks”. During the initial phase, this project was predicted to contribute
towards decreased costs and improved healthcare outcomes, particularly for rural populations.
Although the specifics of project were not announced, it is expected to be based upon mHealth technology.
Chairman of Apollo Hospitals Group says: “With the availability of wireless technology, mobile health
will be integrated into the healthcare delivery system”. The new mantra could well be “Healthcare for
anyone, anywhere, anytime”.
5.3 South America
5.3.1 Project: Cell-PREVEN
Country: Peru
Participant: Universidad Peruana Cayetano Heredia (Peru), Imperial College (London), University of
Washington (Seattle), and Peru’s Ministry of Health
Application Area: Remote Data Collection
Description: When it comes to effective data collection in remote areas of the developing world, there is
less chance that it will occur. Cell-PREVEN was created to allow access to real-time data to members of
the healthcare ecosystem in Peru. This interactive voice response system enables health workers in the
field to collect and transmit data through basic mobile phones. The data are collected in a centralized
database and made available to medical professionals, and the system is designed to send SMS or e-mail
alerts if certain symptoms are recorded. During the three month pilot test, it collected 797 reports
and recorded 374 adverse events enough to trigger an SMS alert to a team leader. The pilot researchers
believe that Cell-PREVEN demonstrates that “cell phones are a feasible means of collecting and reporting
data in real-time in remote communities, it’s not necessary to have the latest Palm Pilot or Tablet PC to
create a sophisticated public health surveillance system.”
5.3.2 Project MediNet Healthcare Management System
Country: Trinidad and Tobago
Participant: Microsoft Research and University of the West Indies
Application Area: Remote Monitoring
Description: The Caribbean is a region with very poor healthcare facilities but a comparatively strong
cellular phone infrastructure. Microsoft Research has provided a grant to professors at the University
of the West Indies to create a mobile phone-based healthcare management system, to be deployed first
in Trinidad and Tobago, followed by a broader regional rollout. The long-term goal is to build a network
that integrates medical resources and promotes the sharing of medical information and expertise. The
healthcare management system, ‘MediNet,’ is targeting diabetes and cardiovascular disease. The system
is designed to relay information from patient monitoring devices to a central server through a cellular
network. At the server, a data reasoning engine extracts all relevant information and alerts medical officers
about severe cases. It also recommends appropriate responses such as a follow-up visit or phone call. The
system can also send suggestions directly to patients through SMS message or pre-recorded voicemail.
5.3.3 Project: Alerta DISMAR
Country: Peru
Participant: The US Navy, the Peruvian Navy and Voxiva
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Application Area: Disease and Epidemic Outbreak Tracking
Description: When disease outbreaks occur, timely transfer of information is important. Alerta
DISAMAR is a disease surveillance system based on Voxiva technology, deployed by the Peruvian Navy
with support from the US Navy. The system’s strength lies in its ‘multi-platform flexibility,’ which allows
users to transmit or access data through multiple technologies, including mobile phones and the Internet.
Alerts of disease outbreaks are also sent through multiple mechanisms (text messages, voice mail, and
e-mail). An evaluation of the project conducted in 2003 found that within the first year of deployment,
Alert a DISAMAR “rapidly improved disease reporting, allowed officials to obtain quality data in real
time, and, most importantly, facilitated improved response to disease outbreaks in a remote region.”
Since its launch, the system has reported more than 80,500 health events over a wide range of medical
problems, including diphtheria, yellow fever, snake bites, diarrhoea, and acute respiratory infections.
5.3.4 Project: Digital Inclusion Kit in Health and Higher Education
Country: Argentina
Participant: University of Buenos Aires, Fundapers (an Argentinean NGO) and the Microsoft Research
Digital Inclusion Program
Application Area: Diagnostics and Treatment Support
Description: Patients in neglected areas in both urban and rural Argentina lack access to specialized
medical centres, which are often the only sites where vital diagnostic tools are available. Researchers
at the University of Buenos Aires are creating a Digital Inclusion Kit in Health and Higher Education
(DIKHAE), which allows smartphones to wirelessly connect to diagnostic tools like electrocardiograms,
enabling sophisticated diagnoses to be conducted remotely. The test results can be stored on the
smartphone until it is in range of a cellular signal, and then uploaded to a patient records system. A pilot
conducted in 2006 received high marks from medical professionals for the system’s usability. Project
sponsors also envision that the DIKHAE is able to connect to X-ray, MRI, and other tools in the future.
6 mHealth use cases in LMIC
6.1 Education and awareness
Description: Short message service (SMS) messages now offer a cost-effective, efficient, and scalable
method of providing outreach services for a wide array of health issues. This service is popularized
by teenagers in western countries, such as Korea, China, and Japan, who wanted a low-cost means
of communicating with friends. SMS messages can be used to send direct messages to users’ phones
in education and awareness applications, to offer information about testing and treatment methods,
availability of health services, and disease management. The effect of SMS alerts has demonstrated that
they have a measurable impact on, and a greater ability to influence, behaviour than radio and television
campaigns by formal studies and anecdotal evidence. Further advantage of b
...