This article originally appeared on the Digital Square blog.
Imagine that a young woman, Ruby, learns she may have been exposed to HIV. She decides to go to an HIV testing facility to get tested, and the receptionist registers her as a new patient in the facility’s electronic medical record system. Ruby proceeds to meet with trained health workers who provide information about HIV rapid testing, administer a rapid antibody test per national guidelines, provide post-test counseling based on the real-time result, and discuss additional HIV prevention and other integrated services available. Ruby decides she’s interested in starting pre-exposure prophylaxis (PrEP), a medication that would offer greater protection against HIV. A clinician confirms her eligibility, counsels her on the medication, and schedules a follow-up visit. The clinician also writes a prescription for PrEP that Ruby gets filled at the nearby pharmacy.
Though not always conspicuous, this experience–with a seamless interplay among clinical recommendations and interventions, workflows, the client, and healthcare professionals–was guided by a digital system closely aligned with World Health Organization (WHO) guidelines. The system logged and mapped Ruby’s data to established data standards to ensure other computer systems could easily recognize and exchange key information, such as her name and location. After Ruby received her HIV test result, the information system updated her electronic medical record. The system also provided staff with reference checklists for clinical protocols and prepared them to anticipate the possible services Ruby could receive. The clinician entered Ruby’s PrEP prescription into the system, which sent it to the pharmacy. The clinician also used a digital system to schedule Ruby’s follow-up appointment for her PrEP refill. Finally, after Ruby’s visit, the system could use her data to calculate PrEP uptake on a regional or national level, one of the many indicators used to monitor programs and improve service delivery.
To employ this type of connected and aligned digital system, WHO, with PATH’s Digital Square initiative and other partners as collaborators, has created a set of products known as digital adaptation kits (DAKs). DAKs provide standardized documentation distilling WHO’s health and data recommendations into a format that countries can localize and incorporate into digital systems. WHO launched the first DAK for antenatal care in early 2021 and since then has published DAKs for family planning and, most recently, HIV. Whether a country is currently using a paper-based system or wants to strengthen its existing digital system, DAKs help ease the transition to a digital system that can be adapted to countries’ needs.
DAKs at a glance
DAKs include various components—such as flow charts and diagrams—that countries can use as a starting point for locally-adapted business process workflows, core data needs, scheduling logic, decision-support algorithms, reporting indicators, and functional requirements. DAKs help systematically translate guidelines into structured content that is adaptable to country needs. Importantly, they are software-neutral, meaning they can be formulated for use with any software platform.
In Ruby’s experience, care providers at the testing facility were able to use the digital system, record her HIV test result, determine if additional tests or retests were needed, and link her to additional care. All of this integration is included in the DAK components and is based on WHO's evidence-based guidance.
Widespread benefits offered by DAKs
By providing structure and a common language, this documentation in the DAKs facilitates and guides discussions among program managers, software developers, and implementers of digital systems. This alignment equips software developers to build digital systems that are based on localized WHO guidelines and reflect best practices in their design, functionality, and content. In return, these digital systems enable swift healthcare decision-making, continuity of care, optimized data use, and the delivery of excellent care. As seen in Ruby’s case, aligned digital systems meant that her experience at the testing facility was relatively frictionless; she received high-quality, connected, streamlined care in line with best practices, ultimately enabling the prevention of HIV.
“For the first time in a while, we have a lighthouse to point to as a framework,” explains Carl Fourie, Digital Square’s Deputy Director of Global Goods. “WHO narrative guidelines have long provided a clear narrative but until now, they have been missing instructions on how to properly translate that narrative into building blocks. DAKs provide that beautiful linkage and a common way to describe the requirements of a health system ready for digitization.”
“DAKs provide that beautiful linkage and a common way to describe the requirements of a health system ready for digitization.”— Carl Fourie, Deputy Director of Global Goods, Digital Square
DAKs are part of a standardized yet localized approach to guideline implementation
DAKs are one of the many resources available to countries to accurately adapt and align their digital systems to WHO guidelines. These resources are part of the SMART Guidelines (Standards-based, Machine-readable, Adaptive, Requirements-based, and Testable) created by WHO to accelerate uptake of the recommendations, systematically reinforce WHO guidelines, and steer guideline localization.
SMART Guidelines are comprised of five layers, labeled L1 to L5, and break down the steps required to transition from paper systems to aligned digital systems. The layers range from narrative instructions of the guidelines in L1 to dynamic algorithms that optimize shelf-ready software solutions in L5. DAKs are the second layer of SMART Guidelines (L2) and help countries document exactly how the digital system should be run, and which functions it should carry out.
What’s next for SMART Guidelines, and DAKs in particular?
Proper implementation and speedy scale-up of the SMART Guidelines and the associated DAKs is essential for making the SMART Guidelines actionable. PATH and Digital Square, along with several other partners, are supporting WHO to develop a set of requirements, criteria, and tests to validate digital health solutions for adherence to the SMART Guidelines through the WHO Digital Health Clearinghouse. As part of this effort, WHO also aims to standardize the representation of the DAK (L2) components and create a core set of common requirements that could be leveraged across DAKs.
Join the global community of countries implementing SMART Guidelines
The SMART Guidelines initiative is focused on translating normative guidance (L1) into the DAKs (L2). The DAKs offer a structured, software-neutral approach to bridging technology and clinical guidance. Countries can use the SMART Guidelines (particularly DAKs and L3) to more easily incorporate national guidelines and WHO’s evidence-based recommendations into digital systems. The DAKs have the potential to radically shift healthcare delivery by providing countries with greater ownership over the definition of health care processes. Adopting common forms like the SMART Guidelines and adaptable tools such as DAKs can help ensure digital systems meet national, regional, and local needs.
A global community is quickly converging to support the use of SMART Guidelines more broadly. Several donors—including the US Agency for International Development; Botnar; the US Centers for Disease Control and Prevention; Gavi; GIZ; The Global Fund to Fight AIDS, Tuberculosis and Malaria; and The Rockefeller Foundation—are supporting PATH to develop and adapt DAKs. Other donors are supporting WHO and associated partners directly, and additional global partners are using DAKs to outline implementation. Government officials are also eager to support and learn from one another, advance and refine the DAKs, and learn how to implement the localized SMART Guidelines at the country level.
To learn more and join the growing community led by WHO, please visit this webpage on SMART Guidelines or contact SMART@who.int.