Dear members,

We're happy to have Ali Habib, CEO of Interactive Health Solutions (IHS) and previously Director of Informatics at Interactive Research and Development (IRD) in Pakistan. He, along with others at IRD, have implemented multiple mobile information systems as well as instances of OpenMRS for Tuberculosis and other diseases. These implementations have been highly successful in improving the health care transactions involved and are also being implemented in other countries as well. Through this member spotlight, we hope to gain from Ali's experience in implementation of these solutions in resource limited settings.

This Member Spotlight will start this Monday, April 8 and go until Friday, April 12.

Usman Raza
Guest Moderator, GHD Online

 
A/Prof. Terry HANNAN
Replied at 7:05 PM, 4 Apr 2013

Usman, it will be very interesting if he can provide some "measures" of functionality as most reports seem unable to confirm "benefits" from mHealth[see my previous postings]. Terry

Sandeep Saluja
Replied at 9:27 PM, 4 Apr 2013

We look forward.

A small query:

How effective is patient communication with a doctor at a distance if the
doctor comes from a different cultural and language background?

Ali Habib
Replied at 2:36 AM, 8 Apr 2013

Hi everyone!

Thanks very much for the introduction Usman! A little bit more about myself
below to provide more context and get the discussion started:

I currently serve as CEO of Interactive Health Solutions (IHS), a
commercial health informatics company recently spun-off from the non-profit
Interactive Research and Development (IRD) in Pakistan. IHS aims to more
efficiently expand and build on the informatics work that IRD has already
done. I’ve been involved with health informatics for more than three years
as Director of Informatics at IRD, before which I got my Master of
Engineering Management at Duke University and was a Fulbright Scholar.

I led the software development and implementation efforts at IRD. This
included both software development, as well as implementation of existing
open source software like OpenMRS and openXdata. The mobile TB screening
system we developed for IRD’s TB REACH project in Karachi, Pakistan is now
being used in several countries including Pakistan, Bangladesh, Kenya, and
Uganda. We also developed XpertSMS, a Stop TB Partnership funded system to
automatically collect results from GeneXpert machines and send
notifications to patients, caregivers, and TB programs trying to reduce
the time to start of treatment.

The informatics team at IRD has also been involved in the deployment of the
OpenMRS MDR-TB (Multidrug-resistant Tuberculosis) module in Pakistan,
Tajikistan, and Nepal. This has included customizing the module to
incorporate local language (i.e. Russian in Tajikistan) and the addition of
a custom calendar to the module in Nepal. The team has also developed a
system to send automated SMS notifications to TB patients, reminding them
to take their daily dose of medicine. In Zimbabwe, my team has deployed
software that uses SMS notifications to help keep track of TB referrals and
reminders for post-up male circumcision follow-up visits.

While a lot of work we’ve done is related to TB, we’ve also been involved
in work on immunization and infection control. We have been working with
the EPI program in Karachi on a system that uses RFID tags to identify
children, and that uses a lottery system to incentivize mothers to get
their children vaccinated on time. Finally, we’ve developed an Android
application to help implement infection control checklists at Indus
Hospital in Karachi. This system uses RFID tagged bracelets to identify
patients admitted into the ICU and CCU at the hospital, and to log events
like insertions of catheters and central lines. It is then used to log test
results in the event that infection occurs. You can see a video briefly
describing this system on our Facebook page at
https://www.facebook.com/photo.php?v=618963264785622&set=vb.247301471951805&t....
Other videos describing IRD’s work are available at http://www.youtube.com/irdresearch

Ali

A/Prof. Terry HANNAN
Replied at 3:05 AM, 8 Apr 2013

Ali, welcome to GHDonline. This web link is one I use regularly and your one posted today seems to be an extension/improvement on this work-correct?
IRDResearch Data visualization using Google Earth: http://www.youtube.com/watch?v=v-3lqG3hSYM Can you discuss the interrelationships? Terry

Ali Habib
Replied at 3:57 AM, 8 Apr 2013

Dear Terry,

That's a very valid question. We don't have studies or data to show
conclusive "benefits" in terms of improved health outcomes but we are
engaged in one randomized control trial to determine the benefit of SMS
reminders to TB patients for improved adherence to treatment.

What we have seen however (and I acknowledge that this is based on
experience as opposed to documented statistical findings), is that the
faster, cleaner data definitely helps us manage projects better. We are
able to react more quickly to resolve problems (example inappropriate
regimens, missed follow-ups etc) than we would have been if we were
operating on paper, simply because we have the data available quicker so we
find out about them faster.

However, this is an area that definitely needs more work, some of which we
plan to engage in on our own projects.

Ali Habib
Replied at 4:04 AM, 8 Apr 2013

Hi Sandeep,

I'm afraid I don't have much experience in the way of direct doctor/patient
communication. Our work has been more around patients interacting with
health workers and field teams. However, are you talking about
communication where the patient and the doctor can see each other? If yes,
then I imagine the effectiveness is much the same as a live interaction (if
the patient is able to understand that the doctor is not actually sitting
there) assuming that a physical exam is not the kind of interaction we are
talking about. Can you elaborate a little on the specific context you have
in mind?

Ali Habib
Replied at 9:19 AM, 9 Apr 2013

Hi Terry,

Apologies. I'm not clear which of the links in my post you're referring to.
The data visualization link that you posted is one of the videos on the
channel that I linked to about work done to map health centres and patients
on Google Earth The other link (the facebook one) is a link to a completely
different application that we developed for infection control.

enock rukundo
Replied at 11:58 AM, 9 Apr 2013

Dear Ali,
I am currently working on a project entitled "sms based, patient referral system in Rwanda". Having read what you did in developing and deploying software that uses SMS notifications to help keep track of TB referrals in Pakistan and in our sister countries like Kenya and Uganda. I was touched by your work and kindly ask for you strategic and tactical guidance to implement the above said project endeavor. Here, we are talking of sms based patient referral system not specifically for TB or Malaria; for any need to transfer a patient from one level to another without passing through various levels looking for the right treatment as indicated in the attached short presentation.

I am kindly asking everyone in our Health IT community to say something maybe you met a related article, an academic paper, a research or you have an EPI to help me implement my dream project for the benefit of the patient and the health facility in general. Feel free to share with me your great knowledge and experiences good people.

Regards,
Enock

Attached resource:

Anne Pao
Replied at 12:12 PM, 9 Apr 2013

Hi Enock,
Are you only interested in learning about SMS technologies specifically
used for patient referrals? I worked on the launch of an SMS appointment
reminder to help patients in Swaziland and can send over the link to that
article if helpful.
Just let me know.

Masimba C. Muziringa
Replied at 12:15 PM, 9 Apr 2013

Really interested in this project

Ron Ribitzky, M.D.
Replied at 12:20 PM, 9 Apr 2013

Hi Enock, kudos for driving a generic solution that would be adaptable to any medical condition and any level.
You're heading the right direction my friend.The PPT is a good start.

Anne Pao
Replied at 12:34 PM, 9 Apr 2013

Hi Masimba,
Here is the article that I co-authored about the launch of the SMS reminder
project which has been ongoing for almost a full year. I am no longer with
the NGO but results will hopefully come out about M&E impacts shortly. My
job was on working directly with our Ministry of Health lead about problem
and solution ideation, requirements definition, implementation and training
of health workers on the system
http://smartsite.kit.nl/net/KIT_Publicaties_output/ShowFile2.aspx?e=1994

Laurien Sibomana
Replied at 12:44 PM, 9 Apr 2013

This is interesting topic !
I am Laurien from Pittsburgh, and would be interested in use of this
tech. for chronic conditions such as diabetes .

Thank you.

L.S.

enock rukundo
Replied at 12:45 PM, 9 Apr 2013

Dear Prof. Ron,

I am terribly sorry for not getting in-touch with for the last cup of days.
And so, let me talk to you directly my Professor... Likewise as you stated
this endeavor can used anywhere its neither cultural nor political....etc.

And to Anne, thank you for the quick offer; please share with me what and
how you did....the link and will possibly get back to you soon.

Much appreciation on how the community is responding to this subject in
question....Keep the spirit. I suspect its generic case to point anywhere
in the developing countries..

Anne Pao
Replied at 12:50 PM, 9 Apr 2013

Hi Laurien,
Here is the article that I co-authored about the launch of the SMS reminder
project which has been ongoing for almost a full year. I am no longer with
the NGO but results will hopefully come out about M&E impacts shortly. My
job was on working directly with our Ministry of Health lead about problem
and solution ideation, requirements definition, implementation and training
of health workers on the system
http://smartsite.kit.nl/net/KIT_Publicaties_output/ShowFile2.aspx?e=1994

enock rukundo
Replied at 12:55 PM, 9 Apr 2013

Dear Health IT Moderators,

Do you think this subject makes sense, should we need to get to the
conclusion on the right system approach.... Please if applicable guide us
on the way forward :?

Laurien Sibomana
Replied at 2:56 PM, 9 Apr 2013

Thank you Anne,
I agree , I would wait for M&E too.
Cell phone number can be reliable in USA and I doubt with developing
countries , but not giving up.

Joaquin Blaya, PhD
Replied at 8:29 PM, 9 Apr 2013

Hi everyone,
I wanted to mention that I've created a new discussion (
http://www.ghdonline.org/tech/discussion/sms-projects-for-patient-referral-vi...)
for the SMS project discussion since it's a bit off-topic for the Member
Spotlight. Let's continue discussing these projects on that new discussion.

For this Member Spotlight, I wanted to ask Ali about what their plans were
for implementing the systems he's described in other countries. I know that
IRD had many implementations that they were doing at the same time, and
that they were getting more requests for additional implementations. If a
project wanted to use some of the systems you have developed or use, for
example the MDR-TB system in OpenMRS, what would be the process and are you
able to do it now?

Warm regards,


Joaquín
___________________________________________________________________
Gerente de Desarrollo, eHealth Systems <http://www.ehs.cl/@@
Research Fellow, Escuela de Medicina de Harvard @@http://hms.harvard.edu/@@
Moderador, GHDOnline.org @@http://www.ghdonline.org/>

Sandeep Saluja
Replied at 8:40 PM, 9 Apr 2013

Dear Ali,

Telemedicine projects may involve either patient interface with health care
professional or health care professional interaction with another doctor or
both.
My own experience has been that the second form of interaction is possibly
easier and more useful while the former is a little tough except as you
mention through video conferencing.
In the latter component(health care professional interaction with another
doctor),one of the challenges is to be able to correctly communicate what
the patient wishes to say. Putting down in black and white or translating a
patient's version may totally distort what the patient wishes to say and
lead to major errors in diagnosis.

How do we circumvent these short comings?

Ali Habib
Replied at 12:34 AM, 10 Apr 2013

Hi Joaquin,

One of the things we have unfortunately been slow to get around to doing is
to start sharing our code online. We're working towards remedying this.

For systems that we have implemented or just customized (as opposed to
developed ourselves) we have typically not had to change code except for
country specific modifications. At the moment this type of work includes
MDR-TB module implementations in Nepal and Tajikistan. The types of
modifications involved were translation into Russian and a change to the
reporting system (because the start and end dates of quarters are different
in Tajikistan) and the introduction of a customized calendar for Nepal
(thanks to Dave Thomas who was with PIH at the time and was extremely
helpful with this). The main codebase for the mdrtb module is available, I
believe, on github, and we have been planning to put these branches there
but have unfortunately been slow to get around to doing that. If there are
groups that would like our help in implementations of this sort, please
send me an email and I can work with you on that.

For systems that we have developed ourselves that are being used
internationally, these are primarily mobile TB screening and patient
management systems that we are, again, in the process of setting up a code
repository for (most likely using github). In the meantime, if you'd like
to see code, please drop me an email and I am happy to share.Alternately if
you'd like us to help customize this code for you, we can do that as well.
For example, the systems that are now running in Kenya, Uganda, and
Zimbabwe are variations on mobile TB screening systems that we developed
for Karachi. We're now in the process of building an Android version of
this system that works with OpenMRS and this system will be rolled out in
the next couple of months.

For both the above types of systems, the way we generally operate is to
first do an assessment which involves someone from our team visiting the
country in question for up to a week visiting the sites, understanding the
data to be collected, data flow, processes, and infrastructure limitations
in the country. The result of the assessment is an implementation plan,
timeline, and a budget for the work to be done. Depending on the work to be
done we also have our implementers on the ground for anywhere between three
weeks and six months in the country to help with setup, training, initial
troubleshooting, training of trainers etc.

Sarah Patrick
Replied at 3:37 PM, 10 Apr 2013

Ali and GHD online members may find this conference an interesting place to share your work -- http://www.hicss.hawaii.edu/hicss_47/apahome47.htm

doctor Moshe
Replied at 2:54 AM, 11 Apr 2013

Thank you All for this discussion.
I would involve our M&E team to join this discuss and benefit on it, as they are currently working on openMRS and SMS sercice used for TB patients. Ali, I think Titi tsolofelo will continue to be in touch with you.
Moshe

Titi Tsholofelo
Replied at 3:39 AM, 11 Apr 2013

Ali..
I am more interested on the mechanism of notifying TB Programme about Xpert Results and also feeding National TB reference Lab with the result of those patients who are Rif+ (Rif resistance). Can you share some parts of the concept note you were using for that project. How do you then get this data into OpenMRS.?

Ali Habib
Replied at 4:35 AM, 11 Apr 2013

Hi Titi!

The way we have set up the patient management system that accompanies the
XpertSMS system, you can send SMS results to patients (just a notification
that result is done), and then more detailed information to caregivers, a
TB programme, and at the moment one other optional number. Next step is to
allow the user to configure what information they want to send to each of
these places.

We're working on the OpenMRS bit at the moment but it will likely be in the
form of a module that accepts the result message, transforms the data into
an OpenMRS encounter and then sends out SMS messages (another thing we're
working on an OpenMRS module for). For areas where Internet connectivity is
not a problem the data transfer to OpenMRS can be done using a REST
webservice call as well. This is expected to be sorted out in the next
couple of months.

Joaquin Blaya, PhD
Replied at 4:50 AM, 11 Apr 2013

Ali,
To send SMS from OpenMRS have you decided if you're going to use the
messaging module or build your own?

If you'd like we've also built an sms module for OpenMRS (
https://bitbucket.org/ehs/smsmodule) if you'd like to use it as a starting
point. This module requires javascript libraries (https://bitbucket.org/ehs/javascriptlibs)

Joaquin
____________________________________________________
Gerente Tecnológico, eHS (www.ehs.cl)
Moderador, GHDonline.org
Fellow, Escuela de Medicina de Harvard

Ali Habib
Replied at 5:02 AM, 11 Apr 2013

Hi Joaquin,

We looked at the messaging module but it relies on SMSlib which has proved
very difficult for us to get compatible phones and modems for here in
Pakistan because most of them are out of production so we've had to scour
mobile phone markets to get compatible devices. So we're working on our own
which provides a UI for SMS but also an API for other modules to be able to
use. Will definitely take a look at the link you shared as well.

Patrick Arida
Replied at 6:04 AM, 11 Apr 2013

Joaquin:

Below a link to a to a research paper about the effectiveness of SMS for for Diabetes patients - I believe this question came up earlier in the dialogue stream. Sorry I'm jumping on this conversation late but the millitary medical department (US) has also had success in reaching remote patients through SMS not so much for chronic disease but more so to quickly capture 'dwindling' mental state and they code actually annotates a level of urgency so the provider/respondent know how to react.

http://www.journalmtm.com/2012/a-meta-analysis-of-mobile-health-and-risk-redu...

A/Prof. Terry HANNAN
Replied at 6:38 AM, 11 Apr 2013

Patrick, this response is very valuable. Also your submission is meeting the aims of this site regardign knowledge sharing. Terry

enock rukundo
Replied at 7:06 AM, 11 Apr 2013

Dear Ali,

Here's what i stated as a problem and proposed a solution architecture
where need your guidance and expertise; a person named as my (Poor Dad)
received 6 transfers instead of one that would suffice...In Rwanda like
many other Countries, ideally a patient should enter or start from the
low-level i.e a Health center (HC) and in these HC (s) no specialist,
usually nurses and atmost one general medical practitioner available. Then
depending on the patient illness he/she should be transferred the next
level health facility i.e District Hospital (DH) and here also specialists
are limited to priority fields or non available. Then if a patient severity
illness) continues he/she is transferred from the DH to the Provincial
Hospital (PH) and then to the referral hospital (RH). All these level
accepts the local medical insurance named (Mituelle de Sante) for common
person. However, medical insurance don't cater for patients transport,
meals, accommodation along the transfer circle (chain) as stipulated
above.

And as a result, we are trying to say it is not by the Ministry of Health
Policy or Regulation that a patient should enter into such long chain i.e
from the HC to RH (almost 5 to 6 transfers encountered). We are proposing
an SMS BASED, PATIENT REFERRAL SYSTEM that would help make a one at a time
transfer of patients be it chronic or any type of disease....

Here is our DETAILED proposed structural process of HOW the system would
look like:

1. The Nurse (Sender in this case) sends a standard coded sms to (*OpenMRS
messaging Module or build our own for:*) with patient details (the
challenge here is *what information that should be sent reflection true
status of the patient*:?, no pictures or attachment only text sms: Remember
here i mean the HC already made their mind (decision) to transfer the
patient but wants to allocate him/her to the right health
facility/specialist not simply moving patients from one level to another
i.e from the Health Center (HC) to District Hospital (DH).



2. The OpeMRS encounter named in my PPT (intermediary filter application)
re-shapes text sms’s into readable web based or emails formats (not sure
about this:?) and sent to the operator/moderator (in this case the
specialist).



3. Moderator reads case details and decides the patient most appropriate
health facility that would respond to the patient case or seek guidance
from a well positioned specialist most appropriate for the patient case i.e
meaning that he/she should agree to work/volunteer i.e this referral system
should be a network of people who trust each other and want to collaborate,
capacity building and social engineering are thus very important:? But as
you all ealier stated what sms information to be fed to the moderator in
deciding the right choice and the organizational set-up and skills of the
moderator is critical?



4. An automatic email sent to the specialist for response or to the nurse
sender if the decision was made by the moderator?



5. Specialists logs in the server, reads the case history and provides a
response to the moderator and the sender.



6. The HC-Nurse (Doctor) i.e the Sender (Referrer) reads response from the
operator/moderator



7. The sender i.e referrer reports action being taken (patient transfer
action made effective)

Am terribly sorry for giving a lot but I had to do so for better visibility
and understanding of my project context…please kindly tell me which one is
which i.e your better guidance and clarifications would be awesome! And
finally, other related and similar question to ali would be do you think
this system is feasible, what challenges you encountered while developing
and deploying related settings? Would you kindly list key critical steps
necessary for this system other than mine i.e adding, merging or deleting
some that are not relevant? Just to let you know that the Rwanda Ministry
of Health decided/opted to go OpenMRS i.e all Government health facilities
and my question would be do you think they would better communication with
OpenMRS if its messaging module is developed/ existing or shall we will
need to develop our own or simply start a new organizational set-up from
scratch? Let me stop here otherwise I might end up repeating myself if not
the case:-)!!!

Thank you so much good people….kudos.

Joaquin Blaya, PhD
Replied at 8:27 AM, 11 Apr 2013

Thanks Patrick this article is extremely helpful. I've attached your
comment as well as the pdf in the other discussion on SMS systems

http://www.ghdonline.org/tech/discussion/sms-projects-for-patient-referral-vi...


Joaquín
___________________________________________________________________
Gerente de Desarrollo, eHealth Systems <http://www.ehs.cl/@@
Research Fellow, Escuela de Medicina de Harvard @@http://hms.harvard.edu/@@
Moderador, GHDOnline.org @@http://www.ghdonline.org/>

Ali Habib
Replied at 10:10 AM, 11 Apr 2013

Hi Enock,

Thanks for explaining this in detail. To avoid parallel discussions on the
same topic, I have responded to this at
http://www.ghdonline.org/tech/discussion/sms-projects-for-patient-referral-vi...

Ali Habib
Replied at 10:38 AM, 11 Apr 2013

Patrick, thanks very much for sharing the article on mHealth for DM
management. We're looking at mhealth for DM management ourselves and this
is very helpful. Having documented evidence that mHealth interventions have
been effective is brilliant!

Ali Habib
Replied at 11:02 AM, 11 Apr 2013

Dear Sandeep,

I'm admittedly a little out of my depth on this one, partly because my
telemedicine experience is limited and I am not sure about what information
needs to be available for a diagnosis to be made. But for any remote
diagnosis I imagine there is a need to codify information in a standard way
so that things are not misunderstood and room for error or confusion is
minimized. Systems like OpenMRS have concept dictionaries that can easily
be translated and used for this sort of thing. Of course when I say the
translation is easy I mean it's easy technically. However, the translation
needs to be done by someone who understands the context and knows
medical/clinical terminology. A mistranslation can have serious
repercussions and this is why that needs to be done carefully. OpenMRS
allows you to switch back and forth between languages very easily. If the
communication is done through such a system and translations are done well,
that can be useful in getting information across accurately. As an example
of how this might work for a hypothetical language X

English COUGH might translate to FOO in X
and WEIGHT LOSS might translate to BAR
TUBERCULOSIS in English might translate to BAZ

The health professional (who speaks X and has set X as the language for the
system) enters the observations into the system as FOO and BAR. When the
doctor (who speaks English) and has set English as the language for the
system logs in he/she sees COUGH and WEIGHT LOSS and is able to understand
that. The doctor enters the diagnosis as TUBERCULOSIS in English. The
health care professional (when they log in) see BAZ. All of this assumes
that the patient and the health professional speak the same language and so
the health professional has entered the data correctly into the system.

I may be misunderstanding or oversimplifying the problem you posed.
Apologies if that's the case. As I said, I'm a little out of my depth on
this one. I hope this was helpful.

Ivy de-Souza
Replied at 6:33 PM, 11 Apr 2013

Enock that sounds good. Whiles l try to get you some literature soon, l also suggest you take into consideration the structure design of the project. For example contact some mobile phone companies and negotiate for the the right phone that can do the work at moderate prices as well as communication companies for toll free or less charge sms and (access helpline) 24/7 connection. You might also consider pilot project between few hospitals and based on progress extend it in the rest of the hospitals in Rwanda.
You may meet The FrontlineSMS for Healthcare team via http://frontlinesms.ning.com/group/health for more ideas. All the best. Ivy de-Souza

Usman Raza
Replied at 9:31 AM, 15 Apr 2013

We would like to thank Ali for his participation in this Member Spotlight.
It has been a very interesting week with the discussion covering a number
of mHealth issues. Use of telemedicine and the inherent challenge of
quality of patient interaction, use of SMS for improving the various
aspects of the healthcare transaction in a variety of diseases/conditions,
RFIDs as a method of patient identification have been talked about and are
being implemented not only in Pakistan but also in other countries facing
similar health systems challenges.

Of note is the fact that conclusive benefits of these solutions in terms of
health outcomes are yet to be proven through scientific trials, but as Ali
pointed out, experience suggests that fast and accurate data sharing that
is easier to validate, is leading to better quality of treatment provided.

We also want to thank the members who participated in the discussion and
hope that the questions and issues discussed will help generate new ideas
and connections.

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