Abstract
The digital revolution has transformed many industries, and healthcare is no exception. In low- and middle-income countries (LMICs), digitization of clinical processes can improve healthcare delivery, patient outcomes, and healthcare system efficiencies. This chapter examines the current state of digitization of clinical pathways in LMICs and highlights the challenges and opportunities in accordance with its implementation. It also examines the impact of digital technologies on various aspects of clinical pathways, such as diagnosis, treatment, monitoring, and follow-up. The potential benefits and risks of digitization are discussed, including data security, privacy, and fairness issues. Based on a review of the relevant literature, the chapter aims to provide an insight into the potential of digitization to revolutionize healthcare in LMICs.
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Keywords
- Digital healthcare
- Digitisation
- Low-and middle-income countries (LMIC)
- Clinical pathway
- Follow-up
- Remote monitoring
1 Introduction
In recent years, the digital revolution has transformed how healthcare is delivered, managed, and accessed worldwide. While high-income countries have digitized healthcare, low- and middle-income countries (LMICs) face unique challenges and opportunities in digitizing clinical pathways. Despite resource constraints, LMICs recognize the potential of digitization to improve clinical workflows, healthcare delivery and fill existing gaps in patient care. This chapter examines the digitization of clinical pathways in LMICs and highlights the opportunities, challenges, and potential impact on health outcomes.
LMICs are rapidly adopting digital technologies to address various socioeconomic challenges. Digitization offers many opportunities to help these countries improve their healthcare, education, governance, and economic development. The health infrastructure and lack of resources in LMICs pose significant challenges to providing adequate health services to their populations. The World Health Organization (WHO) and the United Nations (UN) have highlighted the key challenges related to the limited health infrastructure, shortage of health workers, and insufficient access to quality health care in these regions.
LMICs often face significant limitations in their healthcare infrastructure, which include a lack of modern healthcare facilities, limited availability of medical equipment, and inadequate healthcare management systems. These shortcomings can hamper the delivery of timely and effective health services to vulnerable populations. In addition, the situation is exacerbated by the lack of medical professionals. Many LMICs struggle to attract and retain qualified health workers, including doctors, nurses, and other health workers. This shortage of skilled professionals results in increased workloads and lower quality of care, limiting the ability to meet healthcare needs. The WHO (2018a, b) highlighted the problem of limited health infrastructure and shortage of health workers in LMICs. These problems prevent these countries from building and maintaining sound health systems and hamper their ability to provide adequate health services to their citizens.
Inadequate access to quality medical services is one of the main problems. In LMICs, a significant portion of the population faces barriers to accessing quality healthcare services. Financial constraints, geographical remoteness, and inadequate transportation infrastructure are the main factors limiting these regions’ healthcare access. As a result, many people lack access to timely healthcare, and leading organizations and various stakeholders are investing in developing healthcare infrastructure, strengthening the healthcare workforce, and implementing policies that ensure equal access to quality healthcare services for all LMIC citizens.
2 Gaps in the Clinical Pathways also Affect the Digitization Process
Health systems in LMICs face numerous challenges in providing effective and timely care to their populations. Two notable gaps in clinical care pathways that significantly impact service delivery in LMICs are fragmented care systems, poor coordination, inefficient referral processes, lack of coordination and late care. In several LMICs, healthcare systems are fragmented, involving many public and private healthcare providers with limited coordination and communication between them. This fragmentation often leads to duplication of effort, inefficient resource allocation, and fragmented patient care. As a result, patients may have difficulty navigating a complex healthcare system, leading to suboptimal health outcomes and increased healthcare costs (Baker et al. 2018a, b). A lack of coordination among healthcare providers in LMICs can further exacerbate problems in chronic disease management and continuity of care. Patients may find it difficult to access different levels of care, such as primary, secondary, and tertiary care, leading to delays in diagnosis and treatment. In addition, poor communication between first responders and professionals can disrupt the smooth care flow.
Inefficient referral processes and delayed assistance: The referral process in many LMICs can be slow and inefficient, delaying patients’ access to specialized care. Primary care providers often lack clear guidelines for appropriate referrals, and referral pathways can be confusing and bureaucratic. As a result, patients can experience significant waits before seeing a specialist or receiving primary diagnostic testing and treatment (Bazemore et al. 2018a, b). Delays in the referral process can lead to disease progression, worsening of symptoms, and higher In addition, in rural or remote areas where access to specialized health services is limited, late referral can have serious consequences for patients and make it challenging to treat complex diseases adequately. LMICs should focus on improving healthcare coordination and implementing effective referral processes to fill these gaps in clinical care pathways. This can be achieved by developing integrated healthcare systems that facilitate collaboration between different healthcare providers, including the public and private sectors. Additionally, investments in health infrastructure, staff training, and public health initiatives can further strengthen health systems in LMICs, improve patient outcomes, and ensure equitable access to quality health services.
Digital Healthcare Solutions. The uptake of digital health solutions in LMICs offers enormous potential to improve the accessibility, quality, and efficiency of healthcare. Telemedicine, mHealth applications, and electronic health records can help to close the gap between patients and healthcare providers, especially in remote areas. In addition, artificial intelligence (AI)-based diagnosis and data analysis can aid disease surveillance and personalized treatment, improving health outcomes (Smith and Johnson 2020).
e-Government Services: Digitalization has the potential to revolutionize health public services in LMICs through e-Government initiatives. Online portals, digital payment systems, and e-voting can simplify administrative processes and increase transparency and accountability in governance. This can increase citizen engagement and participation, ultimately contributing to inclusive development (Rahman and Khan 2021).
Digital education and e-learning. The introduction of digital technologies in education can provide access to quality learning resources and promote skills development in LMICs. E-learning platforms, open educational resources (OER), and digital classrooms can empower learners and teachers by removing barriers to education (Li and Patel 2019).
Financial Inclusion and Digital Payments. Integrating digital payment systems can significantly improve financial inclusion in LMICs. Mobile banking, digital wallets, and fintech solutions can provide previously unbanked populations access to formal financial services, contributing to economic growth and poverty reduction (Gupta and Singh 2022).
The possibilities of digitization in LMICs are large and diverse. By harnessing the power of digital technologies, these countries can overcome traditional barriers to development and accelerate progress at different healthcare system levels. However, challenges such as digital infrastructure, digital literacy, and data protection need to be addressed to realize digitalization’s full potential in LMICs.
Mobile health (mHealth) technologies also play an essential role in digitizing clinical workflows in LMICs. In recent years, mobile phone usage has reached unprecedented levels in LMICs, owing to the increasing availability of affordable smartphones and reliable mobile networks. This surge in cell phone penetration presents a unique opportunity to apply mHealth technologies in clinical practice to address the health challenges these resource-constrained regions face. Thus far, potential benefits and applications of mHealth technologies in LMICs focus on remote consultations and patient follow-up. The GSM Association (commonly referred to as ‘the GSMA’ or Global System for Mobile Communications, originally Groupe Spécial Mobile) is a non-profit industry association representing the interests of mobile network operators worldwide, and has reported consistently on the potential of mHealth technologies, as for example in the GSMA Comprehensive Report on Pervasive Mobile Phone Penetration and Use in Low- and Middle-Income Countries (2021). In addition, Michael et al. (2019) provide valuable information on the use of mHealth applications for remote consultation and patient monitoring. The study shows how mHealth can help physicians bridge geographic distances and reach underserved populations. Additionally, mHealth apps offer the potential to increase public and patient engagement and adherence to treatment plans through timely reminders and educational resources. These technologies could facilitate telehealth services by allowing healthcare professionals to remotely counsel and monitor patients, especially in hard-to-reach areas with limited access to medical facilities. Introducing mHealth technologies into clinical practice can revolutionize healthcare in LMICs. However, challenges such as digital infrastructure limitations and data security issues need to be addressed to fully realize the potential of mobile medical applications to improve health outcomes and facilitate the access to quality healthcare in LMICs.
Telemedicine and teleconsultation services have become transformative clinical solutions for LMICs, offering innovative ways to break down geographic barriers and expand access to healthcare. This section examines the use of telemedicine and successful teleconsultation initiatives in LMICs, drawing on crucial references, namely “Expanding Telemedicine to Break Geographic Barriers” (Sood et al. 2018) and “Successful Teleconsultation Initiatives in LMICs” (Labrique et al. 2017). Geographical barriers have long hampered the equitable delivery of health care in LMICs, often resulting in remote and underserved populations not having adequate access to health services. Sood et al. (2018) emphasize the potential of telemedicine to fill this gap. Using digital communication technologies, telemedicine can bridge distances and bring virtual medical consultations, diagnosis, and treatment to patients regardless of their geographic location. Expanding telemedicine services has shown promising results in reducing healthcare inequalities, ensuring timely medical intervention, and improving health outcomes in LMICs.
In addition, Labrique et al. (2017) highlight successful teleconsultation initiatives that have significantly contributed to healthcare delivery in LMICs. These initiatives used mobile technology, internet connectivity, and telecommunications infrastructure to connect patients in remote areas with skilled health workers in urban centers or specialized health facilities. Through real-time audio and video consultations, teleconsultation services have simplified remote diagnosis, medical consultations, and treatment plans, optimizing resource allocation and improving patient management in resource-constrained environments.
The convergence of telemedicine and teleconsultation services has paved the way for cost-effective and efficient healthcare solutions in LMICs. These technologies have strengthened primary healthcare systems and facilitated collaboration between healthcare providers, allowing them to share experiences and knowledge over long distances. Despite problems with limited internet connectivity and technological infrastructure in some regions, the introduction of telemedicine and teleconsultation services has shown promising potential for increasing access to healthcare, reducing healthcare costs, and improving the quality of care in LMICs.
Thus, such services have become tools to transform clinical pathways in LMICs, remove geographic barriers, and expand access to healthcare. The success of teleconsultation initiatives in low- and middle-income countries highlights the potential of such technological interventions to revolutionize healthcare delivery in resource-constrained settings and contribute to more equitable and efficient healthcare systems worldwide. As technology advances, more research and investment in telemedicine are needed to maximize its impact on health outcomes in LMICs and beyond.
Electronic health records (EHRs) have become a revolutionary tool in healthcare and offer significant potential to improve data availability and quality. In LMICs, implementing EHR systems in clinical practice has gained attention as a means to improve healthcare delivery and patient outcomes. The integration of EHR into clinical pathways in LMICs can be seen two landmark studies: Implementation of EHR Systems to Improve Data Availability and Quality (Rajbhandari et al. 2020) and Successful Implementation of E HR in Resource-Constrained Environments (Fraser et al. 2021).
Rajbhandari et al. (2020) showed that introducing EHR systems in LMICs can significantly improve data availability and quality. By digitizing medical records and streamlining data management, electronic health records give healthcare professionals real-time access to critical patient information. This accessibility facilitates timely decision-making and enables efficient and personalized patient care. In addition, electronic health records facilitate data standardization, improving data quality, increasing research capacity, and supporting evidence-based practice. Fraser et al. (2021) provided valuable information on the successful implementation of EHR in resource-constrained environments and highlighted the feasibility and benefits of implementing EHR systems in LMICs. The study underscores the importance of addressing issues such as limited infrastructure, internet connectivity, and lack of human resources. Successful implementation of EHR in LMICs requires tailored solutions that include scalable and cost-effective technologies with a focus on ease of use and training of healthcare professionals.
However, implementing digital clinical pathways in LMICs is challenging. These issues include funding constraints, interoperability, and privacy concerns. A lack of financial resources can impede the large-scale implementation of EHR, thereby impeding the widespread adoption of digital clinical pathways. Interoperability between different EHR systems and healthcare organizations is critical for effective data sharing and care delivery, but it can be challenging to achieve in all healthcare organizations. In addition, ensuring privacy and data security remains a priority when moving to digital systems to maintain patient trust and comply with regulatory requirements.
EHRs offer significant opportunities to improve healthcare in LMICs by improving data availability, quality, and overall patient care. The studies cited in this summary illustrate the benefits of introducing EHR into clinical practice and underscore the need to address challenges for successful implementation in resource-constrained settings. Overcoming these barriers will be critical to realizing the major features of EHRs and transforming healthcare in low- and middle-income countries.
Technical infrastructure and connectivity significantly impact the digitization of clinical processes in LMICs. Healthcare systems in LMICs face significant challenges in using technology to improve clinical pathways and patient outcomes. This summary examines critical technical infrastructure and connectivity issues associated with clinical pathways, drawing on two key references: “Limited internet connectivity and inadequate network infrastructure” (Vital Wave 2019) and “Compatibility issues with existing healthcare systems and technologies” (Tamrat et al. 2018).
The 2019 Vital Wave report highlighted the problem of limited internet connectivity and inadequate network infrastructure in LMICs. This limitation prevents the effective implementation of digital health solutions, telemedicine, and health information exchange systems, which are important components of optimized clinical processes. The lack of reliable internet access impedes the seamless exchange of patient data, diagnostic results, and medical records, disrupts the continuity of care, and creates problems in the coordination of complex clinical processes. In addition, a study by Tamrat et al. from 2018 pointed out compatibility issues with existing healthcare systems and technologies in LMICs. Integrating new technologies into an established healthcare infrastructure can be challenging, often leading to interoperability issues and data silos. This lack of interoperability impedes a smooth transition to digital clinical workflows, reduces efficiencies, and limits the ability of healthcare professionals to make informed decisions.
Comprehensive strategies and international collaboration are required to remove these technical barriers to the clinical management of LMIC. Building a reliable network infrastructure and improving internet connectivity should be a priority to ensure reliable and secure transmission of patient data. In addition, health policymakers and stakeholders need to invest in interoperable health technologies that seamlessly integrate with existing systems. This integration can lead to improved coordination of care, data sharing, and patient engagement, ultimately contributing to improved health outcomes in LMICs. Thus, technical infrastructure and communications remain key challenges in driving clinical referrals in LMICs. Faced with the impact of limited internet access and interoperability issues, healthcare stakeholders can work together on transformative solutions that prioritize the adoption of digital healthcare services, thereby ensuring equitable access to quality healthcare for all.
Costs and sustainability play an important role. Effective implementation of clinical pathways in LMICs is hampered by the interplay of cost and sustainability factors. This summary addresses the challenges in achieving optimal patient outcomes in the face of financial constraints and the long-term viability of clinical pathways in LMICs. Financial constraints and limited resources for technology investments have been identified as significant barriers to successfully implementing clinical pathways in LMICs (Nelson et al. 2019). Due to tight funding and limited access to modern healthcare technologies, LMICs struggle to keep up with the rapidly changing healthcare landscape. As clinical pathways are often based on state-of-the-art digital health interventions, financial constraints challenge their widespread implementation.
Additionally, the long-term sustainability of digital health interventions is a key issue for LMICs (Sarker et al. 2020). While these interventions may be promising in the short term, maintaining and maintaining such technologies over long periods becomes a challenge. In many cases, financial support for initial implementations may not cover ongoing maintenance costs, leading to failure and even abandonment of clinical pathways. Incorporating cost and sustainability considerations into the design and implementation of clinical pathways in LMICs is critical to improving health outcomes and addressing these countries’ unique challenges. By recognizing and overcoming financial constraints and with a long-term vision, countries with low- and middle-level health care in these regions can move forward.
Digital literacy and user adoption are also essential factors in the speed of adoption and usage. Advances in digital technologies have profoundly changed the healthcare sector, promising better patient outcomes and more efficient healthcare delivery. However, the successful implementation of digital clinical pathways in LMICs faces significant challenges regarding digital literacy and user adoption. This summary examines the impact of these challenges on the implementation of digital clinical pathways and possible solutions to address them.
Gyau et al. (2020) highlighted the uptake of digital literacy among healthcare professionals and patients in LMICs. Limited access to digital tools and technologies can prevent healthcare providers from using digital clinical pathways effectively, leading to suboptimal adoption and potential resistance to the implementation of these technologies by healthcare professionals. Additionally, patients’ limited digital literacy may impede their active participation and understanding of clinical processes, reducing the overall effectiveness of these interventions.
Another obstacle to the widespread adoption of digital clinical pathways in LMICs is resistance to change and digital skepticism, as Khoja et al. highlighted (2019). Healthcare systems in these regions often have deep-rooted traditional practices, and any adoption of digital tools can be met with reluctance and fear. This resistance can prevent the integration of digital clinical pathways into existing healthcare workflows and prevent them from realizing their full potential to improve patient outcomes.
Addressing these challenges requires a focus on improving the digital literacy of healthcare professionals and patients in low- and middle-income countries. Education and training programs that equip healthcare professionals and individuals with the necessary digital skills and knowledge are critical to acceptance and confidence in digital clinical pathways. In addition, efforts should be made to increase awareness and understanding of the benefits of digital technologies in healthcare in order to overcome skepticism and resistance to change. Successful implementation of digital clinical pathways in LMICs depends on addressing digital literacy issues and user acceptance among healthcare professionals and patients. Improvement can be achieved by proactively addressing these challenges through targeted education and awareness-raising initiatives.
3 Conclusion
The digitization of clinical workflows holds enormous potential to transform healthcare into LMICs. Despite the challenges, several successful initiatives have demonstrated the feasibility and impact of digital technologies to improve access to healthcare, improve care coordination, and enable data-driven decision-making. To reap the full benefits of digitization, LMICs must remove infrastructure constraints, ensure long-term sustainability, and invest in digital literacy and user adoption. A concerted effort between policymakers, healthcare professionals, technology providers, and international organizations is essential to realize the full potential of digital clinical pathways in LMICs.
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Marino, D., Harutyunyan, A., Sargsyan, K. (2024). Digitization of Clinical Pathways in Low- and Middle-Income Countries. In: Kozlakidis, Z., Muradyan, A., Sargsyan, K. (eds) Digitalization of Medicine in Low- and Middle-Income Countries. Sustainable Development Goals Series. Springer, Cham. https://doi.org/10.1007/978-3-031-62332-5_12
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