Towards Adoption of Standards for Communication

Infrastructure/Technologies in Healthcare Systems in LMICs:

Theories, Practice and Evaluation

Andrew Alunyu Egwar

1,2

, Richard Ssekibuule

and Josephine Nabukenya

Department of Computer Engineering, Busitema University, Tororo, Uganda

Department of Information Systems, Makerere University, Kampala, Uganda

Keywords: Adoption, Communication Infrastructure, Health Information Exchange, Ehealth, Readiness, Standards.

Abstract: While electronic health offers great promise to improve healthcare in low and middle-income countries

(LMICs), the communication infrastructure/technologies (CI/T) requires standards to improve the current

state of none to limited interoperability. This study reviewed theories that inform the assessment of the health

system’s readiness to adopt ehealth CI/T standards. The study involved a scoping review of published articles

reporting adoption to the use of ICT, technologies, and standards in health. Articles published in English

between 2012-2019 were identified through PubMed Central and Google Scholar. Also, grey literature from

websites of WHO, standards development organisations and Uganda’s Ministry of Health were searched.

Data extraction involved coding to identify key themes that inform the readiness of health systems to adopt

standards for eHealth CI. Of the 3,817 published articles, only 32 met the inclusion criteria. 17 grey literature

was also included in our discussion. Results identified determinants for eHealth CI/T and that concepts from

the technology adoption theories can be used as metrics to assess readiness to adopt standards for ehealth

CI/T. The metrics for drivers to adopt standards were higher than inhibitors in Uganda’s health system. The

metrics will lead to the development of a readiness assessment framework.

1 BACKGROUND

Electronic health (ehealth) has lately received much

attention from various health stakeholders. However,

much of ehealth technological developments have

remained fragmented and mostly proprietary,

contributing to a lack of interoperability between

health information systems and supporting technology

(Fontaine et al., 2010; Neuhaus et al., 2011; Tamburis

et al., 2012). Consequently, many ehealth initiatives

have not scaled up (Huang et al., 2017; Kiberu et al.,

2017; McCann, 2012). This greatly hinders the

attainment of the ehealth key goal which is access to

health information by authorised persons when and

where required. According to the IEEE standards site,

interoperability is the ability of a system to work with

other systems without special effort on the part of the

user (IEEE Website, n.d.). In this concept,

interoperability allows health data / information

generated by one system to be accessible and

meaningfully reusable to another system, whether or

not they are based on different technologies. Health

system access to data or information is achieved over a

communication network, which should also be

interoperable. This study focuses on the

interoperability of the secure communication

infrastructure required to support health data transfer

and information exchange (Kuziemsky and Peyton,

2016).

Communication infrastructure (CI) consists of

communication hardware, software and network

interfaces that share healthcare information between

stakeholders (Gillwald, 2008; Yiming et al., 2016).

Implementation and use of the CI should follow

uniform standards across the healthcare system.

Standards are specifications necessary for proper co-

existence and interoperability of communicating

systems, necessary for meeting national and

international regulations (Adebesin et al., 2013;

European Telecommunications Standards Institute,

2013; ITU-T, 2012). Standards are rules for common

and voluntary use, decided by one or several people or

organisations (Brunsson et al., 2012). Regards ehealth,

standards guide the capture, storage, exchange, and

secure use of ehealth information (Vincent et al., 2015;

WHO, 2013). For the CI/T, the standards do describe

Egwar, A., Ssekibuule, R. and Nabukenya, J.

Towards Adoption of Standards for Communication Infrastructure/Technologies in Healthcare Systems in LMICs: Theories, Practice and Evaluation.

DOI: 10.5220/0009171907350744

In Proceedings of the 13th Inter national Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2020) - Volume 5: HEALTHINF, pages 735-744

ISBN: 978-989-758-398-8; ISSN: 2184-4305

735

accurately and unambiguously how information is

transmitted over the communication systems (Eduqas,

2015); similarly, ehealth CI standards must explicitly

specify how both the internal and external CI will

transmit health information across the health system.

Although, WHO recognises the need for electronic

transmission of personal requirements to adhere to

standards in health data and technology (WHO, 2013),

Adebesin et al., (2013) argue that adoption must pay

attention to specific requirements of a country such as

the available communication resources of the

communicating parties. In fact, consideration should

be made of the other ehealth and communication

constraints like the finance, human resources, etc

required to establish and maintain such communication

infrastructure. It is argued that, existing global ehealth

standards may not necessarily apply to resource-

constrained environments (Adebesin et al., 2013; ITU-

T, 2009). In this research context, particularly CI/T, the

concept of resource constrain will refer to data

communication inhibitions including but not restricted

to limited bandwidth; limited or no network

connectivity; limited ICT skills; and limited power

supply. Such environments provide unique

infrastructure, technical, and social constraints that

require innovative design approaches and need to be

guided by technology standards, standardized

terminologies, and data format and interoperability

standards (Anderson et al., 2012).

In addition, despite multiple benefits of health

information exchange (HIE) (Rahurkar et al., 2016), it

is challenged with a lack of suitable CI standards

(Kiberu et al., 2017; Uganda Ministry of Health, 2016).

For example, in Uganda’s context, a situation analysis

of its health system showed that 79% of the health

facilities had computers and 56% had some form of

Internet connectivity (Hindemark, 2013; Kiberu et al.,

2017; Ministry of Health, Republic of Uganda, 2015).

However, they are stand-alone, and this, amidst a

genuine acknowledgment for connectivity supporting

HIE poses the need to assess readiness to adopt

standards for ehealth CI/T.

Based on the definition of Rajiv and McLean,

(1998) and Rogers, (1983), who define adoption as a

formal process that may include an agreement between

ehealth stakeholders to use given standards in the entire

health system, we motion that to date Uganda has not

yet formally adopted ehealth standards specific to the

CI/T. In fact, LMICs lack guidelines, criteria, and

frameworks to guide the adoption of suitable ehealth

standards to support their healthcare systems.

Therefore, this study reviewed existing ehealth

standards and the technology adoption theories with an

aim to identify the barriers and motivators to adopting

standards and identify metrics for assessing the

readiness of healthcare systems in LMICs to adopt

standards for ehealth CI/T. Second, we used the

metrics to assess the readiness of Uganda’s health

system to adopt standards for ehealth CI/T.

2 METHODS

Two distinguished methods were used to achieve the

objectives of the scoping review and assessing

readiness to adopt standards. In order to achieve the

objectives of a scoping review, health informatics

literature was retrieved from PubMed Central and

Google Scholar. Additionally, grey literature

(standards development processes and government

reports) were retrieved from through website search. A

full search of PubMed Central was done. The

following keywords were used to retrieve relevant

documents: ‘electronic health’, ‘health information

exchange’, ‘standards’, ‘health technology’,

communication infrastructure’, and ‘resource-

constrained countries’. To exhaust the search,

keywords were replaced with synonyms. The search

retrieved 3,817 peer-reviewed articles on which we

applied the inclusion and exclusion criteria in Table 1.

With the exception of the definition of key

concepts/theories, the study only considered

publications between 2012-2018.

Table 1: Inclusion and Exclusion Criteria.

Inclusion criteria Exclusion criteria

Studies that focus on streamlining healthcare systems

(Health Management Information System, Electronic

Medical Records, etc) to ensure HIE

Studies that only focus on health data capture, processing

and storage or on research evidence, surveillance data,

survey data, or other non-routine sources and types of data.

Studies that focus on standardization of ehealth CI / T,

privacy and security of shared health data / information

Studies that focus on clinical health equipment /

technologies

Studies on ICT, technology & innovation adoption and

or diffusion-based on theories

Studies not specific to ICT technology / innovation

adoption nor based on theories of adoption / diffuse

Studies that examined organizational readiness to adopt

new technology / innovation

Studies that only made general consideration for adoption

of technology / innovation

HEALTHINF 2020 - 13th International Conference on Health Informatics

736

The authors independently coded and later agreed on

the emerging themes. Key themes were refined by a

discussion with experts from Uganda’s MoH.

The method followed to assess readiness to adopt

standards for ehealth CI/T involved the use of

secondary data from Uganda’s health system to assess

the country’s readiness. The data sources include

published articles and reports from the ministry of

health, NITA-U, and UCC that discuss ehealth in

Uganda. We also held informal discussions with 05

experts from the division of health informatics.

3 RESULTS

3.1 Literature Review

Only 53 studies, websites, and reports were included in

reporting the results of the review and subsequent

discussions. Key results of the review are presented in

two parts;

(A) Determinants for eHealth CI/T: Network

infrastructure consists of the hardware and software

resources for an entire network that enables

connectivity, communication, operations, and

management of an organisation’s network (Gillwald,

2008; Yiming et al., 2016). In the ehealth information-

sharing environment, communications include people-

to-people, people-to-things, and things-to-things

communications as well as the physical backbone for

all e-applications (ITU and UIT, 2017). Thus, ehealth

communication infrastructure includes the hardware

and the software of an entire communication network,

and the network backbone that supports healthcare

communication. Components of the CI/T supporting

HIE are shown in Table 2. Current modes of health

data communication include the sharing of text,

images, audio, and video (Al-Safadi, 2016; Widya et

al., 2003). These are multimedia content with high

communication requirements (Widya et al., 2003)

requiring the ehealth CI/T and network backbone to be

fast, flexible, large, reliable and with appropriate

security and privacy measures (Reid et al., 2005).

Table 2: Determinants of Health System Readiness to Adopt Standards for eHealth CI/T.

CI/T components

Brief Description

Use of ICT

networks

How the ICT network that supports healthcare is used as a contributing factor to the success of

ehealth data sharing. In fact, readiness is reflected by how ehealth technology users engage in the

use of existing data-sharing networks (Rezai-Rad et al., 2012).

Available hardware

and software

systems

The health system requires the hardware and software that support health data transmission

requirements. As such the standards must be adopted for these devices, equipment, and physical

security measures to harmonize the diversity and ensure interoperability.

Affordability

This is the organisation’s financial capacity to acquire and maintain ehealth communication

technologies. It also includes the cost of the bandwidth for health data transmission to other health

institutions, cost of hardware and software, maintenance cost and human resources. Similarly,

with ehealth standards, the concern is how accessible, open or affordable the specifications are to

the implementors (Baker et al., 2015).

Quality of

infrastructure

A measure of the quality (regards usability and performance) of the established CI/T.

Inappropriate infrastructure impacts usability and performance and therefore can negatively shape

the user attitudes towards health information systems (Cresswell and Sheikh, 2013). The

telecommunication service provider/governments supply part of the quality. It is important to

regulate the CI quality both internally (within the organisation) and externally.

Level of ICT

literacy and support

personnel

eHealth technology literacy levels of users and expertise of the support personnel are key in the

capture, storage, and sharing of health information. Whereas the perceived high level of ICT

literacy has a positive relationship to the adoption of technology (Ketikidis et al., 2012), anxiety

to use of technology negatively influences such adoption (Mac Callum and Jeffrey, 2014).

Equally, literacy level and support personnel influence the kind of standards adopted to guide the

implementation and use of ehealth CI/Ts.

eHealth CI security

& information

privacy

Privacy and security concerns of patient data and or information necessitates securing the CI/T

supporting HIE. The level of hardware and software security may influence security upgrades

(standards) to be adopted by the health system to protect health data (Rezai-Rad et al., 2012).

Towards Adoption of Standards for Communication Infrastructure/Technologies in Healthcare Systems in LMICs: Theories, Practice and

Evaluation

737

(B) Technology Adoption Theories: Review of the

technology adoption theories guided the selection of

metrics for assessing readiness to adopt ehealth

CI/T standards. Reviewed theories include;

Technology Adoption Model (TAM): TAM

focuses on the motivation of a technology user, the

‘perceived usefulness’ and ‘perceived ease of use’

(Godoe and Johansen, 2012; Taherdoost, 2018).

Perceived usefulness is the degree to which a person

believes the use of a particular system enhances his

or her job performance. Perceived ease of use is the

degree to which a person believes the use of a

particular system is free of effort. Although

perceived usefulness results from extrinsic

motivation (Godoe and Johansen, 2012) output

quality and perceived ease of use (intrinsic

motivation) have an impact on the perceived

enjoyment and perceived usefulness (Taherdoost,

2018). This raises user acceptance of a given

technology and or standard.

Technology Readiness Index: Technology

readiness (TR) index is the inclination to embrace

and use new technologies to accomplish routine

goals (Parasuraman, 2000; Son and Han, 2011). TR

are factors that foster or hinder the adoption of new

technologies (Liljander et al., 2006). It has four

dimensions of both positive and negative

technology-related beliefs, that is, optimism (a

belief that technology offers people increased

flexibility, control, and efficiency), innovativeness

(a tendency to be a technology pioneer and a

thought leader), discomfort (a belief that one can

lose control and be overwhelmed by technology),

and insecurity (distrust and skepticism about

technology and its ability to work properly)

(Parasuraman, 2000). Whereas optimism and

innovativeness are key drivers of technology

readiness propelling users towards new

technologies, discomfort and insecurity are

inhibitors of technology readiness, which hold users

back.

Diffusion of Innovation Theory (DOI):

Diffusion is the process where adopters become

aware of the standards over time and consider it for

adoption (Rogers, 1983). DOI is a process that

occurs as people adopt a new idea, product, practice,

and philosophy (Oliveira and Martins, 2011). The

process begins with an initial few who adapt to the

use of innovation, technology or standards, then

with the increase in their perceived usefulness and

perceived ease of use, more people and

organisations are driven to adopt its use. DOI covers

the technological context (all technologies that are

relevant to the organisation), characteristics of an

innovation (attributes that determine the rate of

adoption) (Baker, 2011), and adopter characteristics

(degree of being early or late adopters of

innovation) (Ramdani et al., 2013; Rogers, 1983).

Technology, Organisation, and Environment

(TOE): The TOE framework has components for

organisation characteristics (characteristics and

resources of the organisation), technology

characteristics, and environment characteristics

(Baker, 2011). TOE has been used to study the

adoption of different types of IT and IS innovations

(Rajiv and McLean, 1998). Unlike DOI, TOE

introduces environmental context besides the

technology and organisational contexts of

technology or innovation adoption. The

environment includes industry characteristics,

support structures, and regulations. The

environment characteristics influence decisions to

adopt and implement technological innovation in

the adopter organisation, therefore play a vital role

in the decision process to adopt technology and or

standards.

Internet Standards Adoption (ISA): According

to Hovav et al., (2004) standards adoption as

represented by the ISA model is a function of the

utility of the standard’s characteristics (individual

perspective) and the environment in which the

adopter operates (community perspective). ISA

framework acknowledges that besides the standards

features having high utility (useful features),

successful adoption requires an adoption

environment that is conducive (Hovav et al., 2004).

Both dimensions must be of high quality for the

standard to be fully adopted. Useful features of a

standard may appeal differently to potential

adopters. However, ISA does not consider

organisation characteristics that are fundamental to

the successful adoption of technologies and or

standards.

Table 3 presents a summary of the metrics

derived from the related technology adoption

theories (models and frameworks) that can be used

to assess readiness to adopt standards for ehealth

CI/T. Since none of the satisfies all the metrics, we

apply suggestion of Ketikidis et al., (2012) to

improved/develop a model to assess adoption in

health, The study argues that components/metrics

form TRI, TOE, and ISA can be integrated to assess

healthcare systems readiness to adopt standards for

CI/T. Thus, the study developed a framework (refer

to Figure 1) that integrates evaluation metrics from

TRI, TOE, and ISA to assess readiness to adopt

standards for CI/T.

HEALTHINF 2020 - 13th International Conference on Health Informatics

738

Table 3: Metrics for Assessing Technology / Innovation Adoption Readiness.

heories

Technology use belief

Characteristic of

adopter Organisation

Characteristics of a

technology / innovation

Deployment Environment

Usefulness Ease of use

Optimis

Innovativeness

Discomfort

Insecurit

Mangt support

Decision process

Organisation size

Use experience

Financial resource

Availabilit

Regulation

Compatibilit

Complexit

Trialabilit

Observabilit

etwork extensity

Related technology

Install base /scope

Competitive use

External support

TAM





  

─ ─ ─ ─ ─



─ ─ ─ ─ ─ ─ ─ ─ ─ ─

TRI





  

─ ─ ─ ─ ─



─ ─ ─ ─ ─ ─ ─ ─ ─ ─

DOI





  

─



─



─

      

─

TOE

     

 

       

ISA





 

─



 

─

   

Key. =Support the metric; =Do does not support metric; ─ =lack of sufficient information.

identified the following about existing global

standards for ehealth; One, there are many and often

overlapping ehealth standards. Two, they are

developed by international standards organisations,

ITU and foreign governments to support ehealth.

Three, existing ehealth standards, both international

and national do support different dimensions of

ehealth. Those aligned to ehealth CI/T supporting

HIE span the breadth of communications of

electronic records, digital images, clinical

communications, and health information

communication. They include but are not limited to

ISO 12052:2017 Digital imaging and

communication in medicine; ISO 13606-5 EHR

communication for Interface specification;

ISO/HL7 27931 for data exchange; IEEE 11073 for

health devices; ENV 13606: Part 2 for archetype

interchange; CR- CEN for quality of service that

support health information interchange; IEEE

1073.3.x–standards for medical device

communications; ISO 27799:2016 for health

informatics information security management in

health; ISO/DTS 14441 for security and privacy of

EHR systems; CR 14301:2002 framework for

security protection of health care communication;

CR 14302:2002 framework for security

requirements of intermittently connected devices;

and ISO 17090-public key infrastructure for digital

certificates (HL7 International, 2017; IEEE

Website, n.d.; ISO, 2017).

(D) Metrics for Assessing Readiness to Adopt

Global Standards for eHealth CI/T: The metrics in

Table 3 can be customised to suitably assess

Uganda’s health system readiness to adopt

standards for ehealth CI/T to support HIE in

resource-constrained environments. The metrics are

categorised in Figure 1 as characteristics of the

standards for CI/T (ehealth CI/T standards),

characteristics of adopter organisation (adopter

environment) and standards implementation

environment (implementation environment)

(Hovav et al., 2004; Ramdani et al., 2013). To

examine the drivers and inhibitors of organisational

readiness to adopt self-service technologies, we

adopted Liljander et al., (2006) ideology; that is, an

organisation is likely to succeed in standards

adoption in cases where there are high optimism and

innovativeness (drivers for standards adoption) than

discomfort or insecurity (inhibitors) in use of the

standards. Drivers for standard adoption relate to

the high utility, while inhibitors relate to the low

utility. Besides, adopting internationally recognised

standards for ehealth CI, privacy and security

should in addition focus on the dynamics of

resource constrained environments, in our case

Uganda.

• Standards for eHealth CI/T – motivators for the

health system to adopt standards for ehealth

technology include availability of the standard;

perceived advantages from the adoption of such

a standard to support the existing and future

technologies; complexity of application stages,

severity of changes it can cause and clarity of

outcomes; possible forward and backward

compatibility with other standards and or

technologies from other vendors; trialability and

observability. Whereas trialability examines the

possibility of piloting and scaling to include the

entire healthcare system, observability is the

Towards Adoption of Standards for Communication Infrastructure/Technologies in Healthcare Systems in LMICs: Theories, Practice and

Evaluation

739

extent to which results of ongoing ehealth CI/T

standards processes can be observed due to the

selective perception of the beneficiary

stakeholders

Figure 1: Framework for assessing health system’s

readiness to adopt ehealth CI/T standards.

• Adopter Health System – the health system

management support, size, financing, standards

use experience, and standards adoption procedure

and use process, are factors that determine the

readiness of the health system and personnel to

successfully adopt and use the ehealth standards.

To assess the existence of any established

structured process for the adoption of the

standard, there is a need to evaluate the

management decision process to adopt and

enforce the use of the standards. Also, the

personnel capacity to comply with the set of

standards is paramount to the overall success of

any standards adoption. The organisational size

and financial capability are also key influencers

of adoption. A great size and a good financial

capacity imply more resources can be allocated to

support the adoption and implementation process

(Maunder et al., 2018).

• Implementation Environment – the standard

deployment environment imposes restrictions on

what is and what isn’t applicable. For example,

the need for patient safety technology may limit

the use of the radio frequency power levels of the

medical / healthcare sensors. We examine the

standards implementation environment in light of

the external pressures arising from the

complexity of the healthcare industry, the scope

of applicability of the standard being considered

across the healthcare system, the standards

competitive use and the existence of any external

support for the use of the adopted standard.

3.2 Assessing Readiness to Adopt

Standards for CI/T

(A) CI/T Status in Uganda’s Health System: As

presented in Table 4, results show that existing CI/T

in Uganda’s health system continues to be

characterized by rigid, small, slow, intermittent /

unreliable and insecure connections (Huang et al.,

2017; Kiberu et al., 2017; Uganda Ministry of Health,

2016).

(B) Status of eHealth CI/T Standards in Uganda:

The desired state is a set of standards that satisfices

all the metrics for the readiness of the health system

to adopt standards for ehealth CI/T. Thus, we review

current ehealth CI/T standards, both global and

Uganda’s as a case of resource-constrained setting.

Despite their existence, these standards have received

little attention in resource-constrained settings, both

via limited or no participation in their development

and or adoption to using (Adebesin et al., 2013;

Alunyu and Nabukenya, 2018). Both authors claim

there is no evidence of adoption or contextualization

of global standards by LMICs in the African region.

In order to examine their claim of no evidence of

adoption of ehealth standards by African countries

other than the ICD codes, we assessed the status of

adoption of ehealth CI/T standards in Uganda’s

health system. Thus, we used metrics for the

evaluation of technology adoption readiness from

Table 3 and obtained the result presented in Table 5.

The results are based on data from government

reports, MoH website, NITA-U website, and UCC

regards the status and use of ICT in healthcare.

Table 4: Current and envisioned standardised ehealth CI/T for Uganda’s health system.

Current state Envisioned state

Nature

Slow, rigid, small, unreliable and insecure

connections

Fast, scalable, robust, reliable, secure and private

connections

Charact-

eristics

• Diverse network devices

• Varied networked departments and services

• Variation in data transmission rates

• Limited/intermittent bandwidth/Internet

• Varied implementation and enforcement of

computer use’ security measure and levels

• Standardised implementation of network devices,

software, network protocols, and processes

• Existence of technical and institutional

interoperability

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740

Table 5: Uganda’s readiness to adopt existing global eHealth CI/T standards.

Global eHealth CI/T

Standards

Status in

Uganda’s

eHealth

Environm

ent

What should the eHealth CI/T Standards be like in Uganda?

Use belief

Characteristic of

adopter

organisation

Characteristics of the

standard

Deployment

environment

Opt

Inn

Dis

Insec

Mgt

Proc

Size

Fin

Ava

Reg

Pat

Plex

Trial

Ext

Rel

Inst

Pet

sup

ISO 11073 U, NA

 

──

       

─

  

─

  

IEEE1073.x-MDDL U, NA

 

──

       

─

  

─

  

ISO 12052:2006 U, NA

 

──

       

─

  

─

  

HL7 27931:2009 NU, NA

 

──

       

─

  

─

  

ISO 11073-91064 NA

 

──

       

─

  

─

  

ENV 13606: Part2 NA

 

──

       

─

  

─

  

CR NU, NA

 

──

       

─

  

─

  

IEEE 1073.3.x NU, NA

 

──

       

─

  

─

  

PISO 27799:2016 NU, NA

 

──

       

─

  

─

  

ISO/DTS 14441 U, NA

 

──

       

─

  

─

  

CR 14301:2002 NU, NA

 

──

       

─

  

─

  

CR 14302:2002 NU, NA

 

──

       

─

  

─

  

ISO 17090

U, A Part

1, 2 & 3

           

─

      

Key: Opt=optimism; Inn=Innovativeness; Dis=Discomfort; Insec=Insecurity; Mgt=Management support; Proc=Decision

process; Size=Organisation size; XP=Use experience; Fin=Financial resource; Ava=Availability; Reg=Regulation;

Pat=Compatibility; Plex=Complexity; Trial=Trialability; Ob=Observability; Ext=Network extensity; Rel=Related

technology; Inst=Install base /scope; Pet=Competitive use; Sup=External support; A=adopted; NA=Not formally adopted;

U=In use; NU=Not in use; =satisfies; =does not satisfy; and ─ =lack of sufficient information.

4 DISCUSSION

Standards are ever-evolving in response to

technological changes and health care needs.

Therefore, Uganda’s health system, as the adopters

and implementers of ehealth standards, should

recognize and adapt to changes. In this study, we

needed to assess the readiness of Uganda’s health

system to adopt standards for ehealth by examining

the adopter organisation (the Uganda health system),

the adopter environment and features of the standard

for ehealth CI/T. We recognise that the lack of

adoption can be attributed to a lack of metrics, and or

systematic procedure for adoption of standards for

ehealth.

Uganda’s health system is challenged by diverse

network and communications systems

implementations (Kiberu et al., 2017; Uganda

Ministry of Health, 2016). As shown in Table 4, the

health system is varied with a number of networked

departments and services, data transmission rates,

intermittent Internet, limited bandwidth, and different

computer-use security levels, among others (Huang et

al., 2017; Kiberu et al., 2017; Uganda Ministry of

Health, 2016). These variations cause unnecessary

delays in data sharing; data loss due to transmission

errors, dropped data packets, and in worst cases a

denial of service; which in the case of emergency lead

to delayed service and eventual loss of life. In

addition, it is clear that Uganda’s healthcare few CI/T

resources (Uganda Ministry of Health, 2016), the

human resources lack requisite skills and technical

support (Uganda Ministry of Health, 2016), lack of

experience in implementation and monitoring

conformance to standards that support the various

dimensions of ehealth CI/T, etc. Such challenges

drive the need for standardised high-capacity

communication systems to handle the high-volume of

healthcare data generated (Song et al., 2014). Thus,

effort must be made to bridge these gaps in the

standardisation of ehealth in LMICs.

The challenges are complicated by the lack of a

structured procedure/process at the health system

level to support the standards adoption and

implementation (Ministry of Health, Republic of

Uganda, 2015). Both the public and private healthcare

facilities have neither reached a level of coordinated

nor interoperable ehealth systems (Hindemark, 2013;

Kiberu et al., 2017). Although NITA-U oversees the

Towards Adoption of Standards for Communication Infrastructure/Technologies in Healthcare Systems in LMICs: Theories, Practice and

Evaluation

741

standardisation of the communication and the

external support for standards implementation in

Uganda (NITA-U, n.d.), they have not adopted,

developed and or harmonised the standards to suit

ehealth communication devices and health system

networks, particularly the unique nature of health data

transmission required for health system

communication in a resource-constrained

environment (Uganda Ministry of Health, 2016). In

fact, the results in Table 5 show Uganda has adopted

only one set of standards i.e., standards for the public

key infrastructure. This cannot work in isolation of

other security or CI/T standards. Other global

standards for ehealth CI/T (in-use or not-in-use) have

not been formally adopted. the existing UCC

communication standards for data transmission do

not explicitly stipulate the minimum specifications

for timely, error-free and secure data sharing

requirements suitable for healthcare (Song et al.,

2014). This means Uganda does not have suitable

standards to support ehealth data communication

requirements for their usually resource-constrained

environments.

The Assessment of standards that have been

developed or adopted by NITA-U as of June 2017

regards ehealth communication infrastructure show,

first, gaps in the statement of minimum requirements

that meet big data communication requirements for a

timely, error-free and secure exchange of health

data/information. Whereas health informatics should

facilitate the coherent and consistent interchange and

use of health-related data, information and

knowledge, NITA-U only adopted ISO 17090 Part 1,

Part 2 and Part 3 of the public key infrastructure for

digital certificates. Second, exposed component areas

of the ehealth communication infrastructure without

standards / minimum specifications to guide

implementation and compliance monitoring.

Examples include network capacity, quality of

service parameters, communication equipment, etc

suitable for healthcare data sharing; and third, show a

lack of consistency in the structure/presentation of

standards. This shows inconsistency in procedure and

manner in which the standards are developed or

adapted. The December 3

– 4

(2012) WHO forum

on health data standardisation and interoperability

discussed perspectives on the health data standards

implementation (WHO, 2012). They relate to the five

antecedents of organisational readiness to adopt

information systems identified by (Aziz, 2012),

which include desired change, leadership support,

organisational context, attributes of change target and

IT support and can be mapped to the three dimensions

of the TOE.

Furthermore, the lag between published standards

and their implementation means that future adoption

and implementation should be a continuous and

cyclic process. Assessment of the health system level

of preparedness to adopt ehealth standards can guide

their decisions to adopt and use standards. Moreover,

ehealth standards adoption can be motivated by the

likelihood to realise the lasting benefits of such

adoption. The benefit of the adoption is a measure of

the success of adoption and in future studies, we will

explore the potential ehealth standards adoption

success for resource-constrained settings.

5 CONCLUSIONS

This study argued that existing global standards

(developers are commonly from high-resourced

environments) may not apply as is to resource-

constrained settings common in LMICs. Thus, need

to be contextualised for applicability in resource-

constrained work environments. However, there is

lack of suitable metrics to assess readiness to adopt

and or adapt the global standards. Therefore, the

study reviewed ehealth literature to establish

determinants of ehealth CI/T and security and metrics

of ehealth standards adoption. The identified metrics

(16 adoption readiness metrics) for assessing

readiness to adopt standards for ehealth CI/T were

used to assess the readiness of Uganda’s health

system to adopt 13 global standards related to ehealth

communication infrastructure and security measures

to support HIE. Based on the situation analysis of

Uganda’s health system as an example of LMICs, it

is a promising mechanism to determine the readiness

to adopt standards for ehealth CI/T for LMICs.

Although the identified metrics for assessing

readiness to adopt standards for ehealth CI/T seem

adequate in guiding the health system’s adoption

decisions, they may not in the current form support

the adoption and adaption processes nor determine

the “structure” of standards suitable for LMICs. In

addition, the review might have been limited by

incomplete retrieval of research on adoption or

diffusion of standards (not indexed by PubMed

Central and Google Scholar) or any reporting bias by

literature considered in this review. Future research

will focus (1) on developing and validating the

readiness assessment framework for ehealth CI/T

standards adoption readiness and exploring the

potential adoption success with an aim to

contextualise it for Uganda’s resource-constrained

health system. (2) Determining the criteria for

selecting standards for ehealth CI/T that resourced-

HEALTHINF 2020 - 13th International Conference on Health Informatics

742

constrained settings like Uganda’s healthcare system

may use to select suitable global standards to support

their HIE. (3) Develop a structured process to guide

the adoption and adaption of ehealth CI/T

standardisation efforts within Uganda’s health

system.

ACKNOWLEDGMENTS

This study was funded in part by the Swedish

International Development Cooperation Agency

(Sida) and Makerere University under Sida

contribution No: 51180060. Also, part of the funds

was provided by Makerere University Research and

Innovations Fund through the project, “Exploring the

Feasibility for Strengthening Uganda’s Health

System through Standardizing Digital Health”.

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