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mHealth Across the Continuum of Care: Strategies for Implementation
CORE Group
Spring 2015 Global Health Practitioner Conference Alexandria, VA
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Agenda
Introductions Background: mHealth Toolkit & Project Examples
Breakout Activity
Report Out/Wrap Up
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Session Objectives
Provide examples of how mobile tools already support the continuum of care Recognize unique challenges and opportunities for
mHealth across the continuum of care Develop a specification for an mHealth program that
could support your health project
Fair Warning: We speak tech better than health – we’ll ask you to help us on the health part!
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About Dimagi
Mission: We deliver open and innovative technology to help underserved communities everywhere
Created out of Harvard and MIT Media Lab
Business units in Cambridge (USA), New Delhi (India), Cape Town (South Africa), Maputo (Mozambique), Dakar (Senegal)
In-country staff in Thailand, Guatemala, Burkina Faso, Zambia
Leaders in Open-Source product development and Software-as-a-Service (SaaS) support for mobile technology
Multi-disciplinary team of 100+ with engineers, field implementers, consultants, scientists, public health experts, and physicians
10+ years of experience with over 150+ ICT projects across numerous sectors and technology approaches
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CommCare used by a Community Health Worker
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Definitions – for today at least
mHealth Any technology or tool that relies upon tablets or phones
(i.e. Apps, SMS, USSD, and yes, phone calls) May or may not integrate with other tools or systems
Continuum of Care “Continuum of care is a concept involving an integrated
system of care that guides and tracks patient over time through a comprehensive array of health services spanning all levels of intensity of care.” (Evashwick, 1989) We think in terms of a continuum in terms of:
• different parts of the health system (ex: community and clinic) • different health issues affecting a person
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Continuum of Care
De Graft-Johnson, Joseph et al. Opportunities for Africa’s Newborns http://www.who.int/pmnch/media/publications/oanfullreport.pdf
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THE MHEALTH TOOLKIT
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mHealth Tools
•Works for low literacy, low cost to end users •High cost and tech difficulty, limited data collection •Twilio, Voto Mobile, CommCare •BCC using client-focused health messages via IVR
Voice/IVR
•Low cost to end users, works on any phone •Higher cost for data collection, limited data & “richness” •RapidPro, RapidSMS, FrontlineSMS, CommCare •Ex. TB program using SMS for receiving lab results linked to
mobile apps for service providers
SMS
•Richer experience (audio, media), lots of data collection •High cost, doesn’t work on all phone (less suited for end clients) •ODK, Magpi, CommCare, etc. •Apps for CHWs and clinics, etc.
Mobile Apps
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Limitations of some mHealth Systems
Data Silos Mobile-based data collection at one level but another system at
another Smaller pilot area -> not worth integrating with other systems
Limited focus Typically focus on one program area or problem CHWs do a lot and activities change over time (campaigns, etc.)
Not Standardized Tools may not follow the national standards exactly (or adapt
existing workflows) Technical Implementation Training users on a new tool
Logistics of maintaining, supporting, distributing tool
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EXAMPLES
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Example 1: CoC Across Health System
Example 1: Close the referral / counter-referral loop Referrals are created at community level (danger signs, new
FP enrollments, etc.), Referral info is provided in a clinic app and sent to the
mobile app for final close App usage is needed on both sides. Is paper more effective?
Example 2: TB Patient Tracking Potential TB patients registered at a clinic using a web-
based application Labs use SMS to report lab results back to clinics TB adherence monitored using mobile tools SMS or voice outreach to TB patients
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Example 2: CoC Across a Person’s Life
Level 0: Basic data surveys for a person (no tracking of data between visits). Replace basic paper tools Level 1: Basic longitudinal data – track a person’s
progress in a given program (ex. pregnancy or family planning) Level 2: Comprehensive tracking a person over time
(household surveys, linking TB, pregnancy, HIV, etc. programs to the same person) Level 3: Linking of patient data at mobile level to other
HIS tools
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Example 3: Integration of systems
MCTS in India Main national government used for tracking pregnancies Non-government mobile based applications used for
registering and following up with pregnancies Integrate two data sources
• Data conflicts? – nurses (ANM) responsible for dealing with conflicts
• “Trust” layers – national system doesn’t accept direct input. Needs approval from ANM
Do manual data entry on either end -> current solution • Prone to error, and duplication of data, but easier than a
complex data integration workflow.
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Some Principles
Start small but plan big Focus your system initially (solve some key problem) but
don’t do it in a way that will stop you from expanding SMS-based logistics limited to few products
Design flexible systems People change providers or move across catchment areas. Sometimes parts of a system just aren’t used (ex. referrals)
and need to be tolerant
Distinguish between data aggregation and interoperability Technical challenges (APIs?), each system evolves on its
own, different “views” of the world (are facilities the same in each, do each have the same set of patients and IDs)
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BREAKOUT SESSION
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Exercise Guidelines
Background on a situation Divide into groups of ~6 people
5-10 minutes to discuss, 5 minutes to report back
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Discussion Question 1
You want to improve loss to follow up from CHWs to the clinic and there are a few ways to address this. Possible solutions: Provide SMS reminders and messaging to patients to remind
them to go to clinics Develop a mobile tool at the clinic to help them view
incoming referrals Update the CHW’s mobile tool to provide reminders to the
CHW to have them check-in on referred clients Improve effectiveness of existing paper-based referral
system
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Discussion Question 2
You want to improve the ability of the district to aggregate and report their data. Potential solutions: Build technology to directly feed CHW data to a national
health system Provide basic web-based or email reports to clinics to allow
them to view data on their CHWs, and they can then provide it to districts in the required format Improve and update the existing paper based workflow that
CHWs, districts, and clinics are using
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Discussion Question 3
Both clinic and CHWs are registering and tracking patients. You want to make sure that patients are receiving care correctly from both areas of the health system. Potential Solutions: Develop one larger system that integrates clinic and CHWs
data, sharing the registration data Make a common user group phone system to help clinics and
CHWs coordinate patients Allow both systems to work independently but have ways to
allow CHW to enter what has happened at the clinic level. Manual reconciliation will occur at data aggregation time (someone’s job).
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Discussion Question 4
One common challenge for mHealth programs is that they focus on only one area of the health system (ex. malaria). Discuss the pros, con and concerns with the two options listed: Focus on a single health area but improve how well it
functions (adding supervision tools, improving counselling content, SMS reminders to clients) Expand to additional health areas (add additional modules
to an existing app, move from SMS to a full mobile app) but less ability to really improve and focus on that one area.
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Guidelines
Divide into groups of ~10 people Each group should get a couple of handouts
Scenario Overview
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Breakout Session Report Out
Report back your group’s discussion: 1. Which area(s) did you choose to focus on (and why)?
• Ex: loss to follow up, expanding the health areas of the mobile tool, improving the data and reporting flows, etc.
2. How did you decide to address this area? • Ex: which tools, how fast, which levels, which health areas,
etc.
3. Describe at least 3 challenges to your proposal being successful
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REPORT OUT & WRAP UP
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Thank you!
Contact us with Questions:
Sheel Shah [email protected]
Michael O’Donnell [email protected]
Jeremy Wacksman [email protected]
Additional Resources:
http://groups.google.com/group/ict4chw
http://www.commcarehq.org
http://www.dimagi.com
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Dimagi Global Head-office 585 Massachusetts Ave Cambridge, MA 02139 USA T: +1.617.649.2214 F: +1.617.274.8393
For more Information E: [email protected] W: www.dimagi.com W: www.commcarehq.org W: www.dimagi.com/category/blog/
