Health IT

About the Millennium Villages Project
The Millennium Villages Project (MVP) offers a bold, innovative model for helping rural African communities lift themselves out of extreme poverty. With the help of new advances in science and technology, project personnel work with members of the communities to create and facilitate sustainable, community-led action plans that are tailored to the villages’ specific needs and designed to achieve the Millennium Development Goals. Simple solutions like providing high-yield seeds, fertilizers, medicines, drinking wells, and materials to build school rooms and clinics are effectively combating extreme poverty and nourishing communities into a new age of health and opportunity. Improved science and technology such as agroforestry, insecticide-treated malaria bed nets, antiretroviral drugs, the Internet, remote sensing, and geographic information systems enriches this progress.
1. The health IT projects used by MVP
Community-Based Health Information System
The MVP implemented the ChildCount+ (www.childcount.org) system across all the MVP sites. ChildCount+ (CC+) is an SMS-based application used by Community Health Workers (CHWs) for reporting as they conduct household visits, but also provides remote decision support for the CHWs via text messages. The main functions of CC+ are for registration of all households heads, children under 5 years and ...

About the Millennium Villages Project
The Millennium Villages Project (MVP) offers a bold, innovative model for helping rural African communities lift themselves out of extreme poverty. With the help of new advances in science and technology, project personnel work with members of the communities to create and facilitate sustainable, community-led action plans that are tailored to the villages’ specific needs and designed to achieve the Millennium Development Goals. Simple solutions like providing high-yield seeds, fertilizers, medicines, drinking wells, and materials to build school rooms and clinics are effectively combating extreme poverty and nourishing communities into a new age of health and opportunity. Improved science and technology such as agroforestry, insecticide-treated malaria bed nets, antiretroviral drugs, the Internet, remote sensing, and geographic information systems enriches this progress.
1. The health IT projects used by MVP
Community-Based Health Information System
The MVP implemented the ChildCount+ (www.childcount.org) system across all the MVP sites. ChildCount+ (CC+) is an SMS-based application used by Community Health Workers (CHWs) for reporting as they conduct household visits, but also provides remote decision support for the CHWs via text messages. The main functions of CC+ are for registration of all households heads, children under 5 years and women in reproductive age; monitoring and documenting, births and deaths; and growth monitoring/malnutrition and immunization tracking in children and following up of pregnant women.

Due to the challenges of adequate mobile network coverage and maintaining different servers in remote areas, the MVP is switching from relying on the SMS-based platform of CC+ to using cloud-based systems including CommCare and Open Data Kit (ODK). The use of android-based cloud systems allows the platform(s) to operate, without continuous mobile network coverage and retain most of the CC+ functionalities (decision support) by running on the phone rather than depending on remote servers. CommCare will be used by CHWs in place of CC+ for registering patients, collecting data, receiving decision support and receiving and providing health counseling. ODK Clinic is used as a tool for Verbal Autopsy, whereby the collection of the autopsy data takes place using a form on the mobile phone. The information is then sent to a central data warehouse through the Verbal Autopsy platform’s link with OpenMRS (an open-source electronic medical record), which makes it easy to investigate and address the main causes of death in the community. The OpenMRS system allows for us to have a single, multi-lingual, multinational data dictionary linking all of our systems into one interoperable data system. The Columbia International eHealth Laboratory (CIEL) manages the dictionary for all of the MVP sites in addition to some 20 other countries around the globe.
Clinic-Based Health Information System
For clinic level reporting, MVP also uses OpenMRS. MVP is able to draw on the support of the active OpenMRS community for implementation and platform adjustments. For the time-being, data entry into OpenMRS is mostly done retrospectively from paper forms and thereafter entered by data clerks from a central place. MVP is piloting the use of ODK clinic for entering clinic information into OpenMRS as well. To allow linking of the clinic- and community-based information, the same Health IDs are used in the community-based applications and are drawn from/connected to the Health IDs generated at the clinic-level through OpenMRS. OpenMRS acts as the central database for both the clinic and community-based platforms, which allows for easy access to the patient history from the community encounters and clinic level cases where health care providers use OpenMRS at the point of care.
2. How these projects have impacted the way in which MVP is reaching the MDGs
To allow continuous tracking of progress towards achieving the MDGs, MVP requires ‘real-time’ monitoring of health indicators. MVP is focusing on using the data collected for improved operations as it guides the planning of interventions and distribution of resources.
CHWs perform case management of malaria, diarrhea and, in some MVP sites, pneumonia. These are amongst the leading causes of preventive deaths in children under five years of age, and the mHealth tools used by over 1,000 MVP CHWs play a great role in identifying and tackling these health issues.
With improved tracking of pregnancy aided by the tools, antenatal care (or ANC) visits and institutional deliveries have improved, and so have neonatal household visits by CHWs. MVP participated with the International Development Research Centre (IDRC) in the OASIS II research to evaluate the impact of eHealth interventions with MVP. The results of this research are still being finalized but will be presented that this Fall’s AMIA meeting in Chicago in November.
These tools also guide the CHWs to the areas that they should focus on as they provide counseling during the day-to-day household visits.

I'd be more than happy to answer questions about these implementation or get comments from the community.

I wonder to what extent the MVPs and the information systems below are integrated or even linked to national health information systems and therefore informing national priorities. It may appear to me like the benefit of the MVP is largely to the researchers and their institutions. Lets note that the use of CHWs and other such community based strategies are an invention of the primary health care movement that followed the Alma Ata conference. Si the intention of the MVP to perfect the use of CHWs. If that is the case, then how is the CHW concept perfected through the MVP for large scale access to effective healthcare at a national levels??

Thanks

Daraus Bukenya

Daraus,

The MVP implements activities guided by national guidelines. For the information systems, some of the countries the MVP is implemented don't have national information systems, but where they are we always make sure that it's within the strategy that the Ministry of Health has or an improvement of it, for instance use of OpenMRS is being implemented by the Ministries of Health in Kenya and also in Rwanda, we are doing the same in MVP. We use the tools used by the national governments to guide on the design of the data that is collected by the Health Information System and also to ensure easy integration into national reporting we ensure that whatever health information system is used can easily integrate into systems like DHIS2 which is used for aggregate reporting from health facilities. The systems used in MVP generate reports which feed into the facility and community health worker monthly reporting to the District/National level.

The focus in implementing information systems in MVP is to provide real time information for improved decision making and not research as you mentioned.

As for the CHWs, it's not an MVP invention. But we have to appreciate that ...

Daraus,

The MVP implements activities guided by national guidelines. For the information systems, some of the countries the MVP is implemented don't have national information systems, but where they are we always make sure that it's within the strategy that the Ministry of Health has or an improvement of it, for instance use of OpenMRS is being implemented by the Ministries of Health in Kenya and also in Rwanda, we are doing the same in MVP. We use the tools used by the national governments to guide on the design of the data that is collected by the Health Information System and also to ensure easy integration into national reporting we ensure that whatever health information system is used can easily integrate into systems like DHIS2 which is used for aggregate reporting from health facilities. The systems used in MVP generate reports which feed into the facility and community health worker monthly reporting to the District/National level.

The focus in implementing information systems in MVP is to provide real time information for improved decision making and not research as you mentioned.

As for the CHWs, it's not an MVP invention. But we have to appreciate that not all countries where the MVP is have a national CHW programme, and where there is, they don't do uniform activities. MVP is more keen on how best the CHWs can be used optimally to improve health care. MVP is involved at national policy level discussions to share some of the best practices and lessons learned from the MVP experience, which benefits the stakeholders formulating national CHW policy.

Thanks

Mourice,
This sounds impressive. I had a couple of questions. How have you found the transition from an SMS based system (ChildCount) to an android based system (CommCare)? Do users like it better, have you found that the more expensive android phones are better or worse...

Also, I believe one of the MVP missions is to be an example of how this these villages can meet the MDGs, have you found that you've been able to have other implementers use these systems int heir implementations?

Joaquín

Joaquin,

The transition from SMS to smart phone is really going well. The exciting feature for the CHWs so far is the multimedia support in form of pictures and pre-recorded counselling messages in their local language. They also like the fact that they don't have to move around with a list of codes that they would refer to when sending the text messages since the text messages in ChildCount+ were coded. The only disadvantage with the smart phones is the battery consumption but this has been addressed through provision of solar chargers.

In terms of working with other implementers to use these systems that we use in MVP. We try as much as possible to share all that we implement in open forums or making them openly available and where possible provide support, for instance we are piloting an application with the Civil Registration Department and the Ministry of Health in Kenya where CHWs will use text messages for vital events reporting, which we worked with them to modify from ChildCount+. We also have the MVP Concept dictionary (Andy may talk more about this next week) for OpenMRS which is widely used by different OpenMRS implementers.

Mourice.

Thanks, Mourice, I am happy to talk more the terminology next week. I think MVP has done a lot of great work in not only piloting new and innovative eHealth technology, but in addressing issues of scalability and working within an international framework. The MVP process is somewhat controversial in that it tends to put a lot of resources into an intensive integrated development effort. eHealth has become an essential component and in many ways extends beyond health into a more comprehensive information ecosystem. We have to design, implement, and evaluate our eHealth applications under the constraints posed by a larger development effort, and the implementers are all local personnel, not informatics specialists. Maurice heads up the East Africa regional office and works with teams in Ethiopia, Kenya, Rwanda, Tanzania, Uganda and Malawi. The platform has to be flexible enough to work with any and all of the different systems in those countries as well as the West African countries of Ghana, Nigeria, Mali and Senegal! We call the integrated, open source platform Millennium Villages Global Network (MVG-Net) which Maurice has explained. It is based on OpenMRS as the core data model and dictionary, but includes multiple different applications depending ...

Thanks, Mourice, I am happy to talk more the terminology next week. I think MVP has done a lot of great work in not only piloting new and innovative eHealth technology, but in addressing issues of scalability and working within an international framework. The MVP process is somewhat controversial in that it tends to put a lot of resources into an intensive integrated development effort. eHealth has become an essential component and in many ways extends beyond health into a more comprehensive information ecosystem. We have to design, implement, and evaluate our eHealth applications under the constraints posed by a larger development effort, and the implementers are all local personnel, not informatics specialists. Maurice heads up the East Africa regional office and works with teams in Ethiopia, Kenya, Rwanda, Tanzania, Uganda and Malawi. The platform has to be flexible enough to work with any and all of the different systems in those countries as well as the West African countries of Ghana, Nigeria, Mali and Senegal! We call the integrated, open source platform Millennium Villages Global Network (MVG-Net) which Maurice has explained. It is based on OpenMRS as the core data model and dictionary, but includes multiple different applications depending on the constraints of the country's infrastructure, human resources, etc. MVP has to work with a fixed maximum of $110 per capita per year to achieve all development goals (build schools, clinics, roads, medicine, staffing...) and the cost of eHealth has to come out of this bucket. Justifying even a couple of dollars per capita on eHealth was a hard sell. This is probably a biased group, but how much emphasis should a program put into information systems versus let's say hiring nurses?

It's interesting because most projects have budgets or financing that is
specifically related to technology for example a USAID or Gates grant, and
those funds don't come to your organization unless you have these kinds of
projects.

Here in Chile, for example, the question of how will this impact health
care and reduce costs is always asked of a technology implementation, but
those funds are usually separate from health care (in some cases they just
feel different because they come from the same budget, but have been
destined by the director for this), whereas in other cases the funding from
the beginning is for projects in eHealth (such as a national EMR project).

So the question of why buy technology versus hiring another nurse is not as
imminent as in your situation. With that said, the evidence for if a
nurse's monthly salary spent on these technologies is more worthwhile has
not been answered.

I don't know if others have felt this tension and how they've dealt with it.

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 ...

The points raised here re a nurses salary and HIT reminded me of a recent publication provided to me for educational purposes by Dr. J. Wennberg of the Dartmouth Institute. The subject matter relates to the complex phenomenon of "variation in health care". On page 21 he in some ways refers to the issues relating to "staffing" and patient outcomes. I thought this would be relevant. The materials in the attached document are solely attributable to Dr. J Wennberg.

As we finish this first of two Member Spotlights, Terry Hannan and I wanted
to thank Mourice for his time and contributions. His his work and that of
the MVP team is incredible even in the brief period we've been able to
learn about it here on GHDonline.

Starting next week we'll hear from Dr. Andrew Kanter on the impact of
eHealth at MVP in the second half of this double impact Member Spotlight.

Again, thank you Mourice for your insights;

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