Contents

When: December 10 - 11th 2018

Where: Washington DC

Attendees: @Rebecca Alban (Unlicensed), @Vidya Sampath, @Swetha Srinath (Unlicensed) and @Mary Jo Kochendorfer (Deactivated)

The following is a joint trip report. Please note that the session notes are quite detailed and some are rough notes. Feel free to leave questions and comments for the authors.

Team spoke on two panels (Mary Jo and Vidya), presented two posters (Swetha and Rebecca), attended lots of sessions, and crammed in lots of meetings in two very full days. Some photos and table of Contents with LINKS below!

Rebecca presented a poster on OpenLMIS.

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Attendee: Rebecca and Vidya

Presenter (panel): @Mary Jo Kochendorfer (Deactivated), @Matt Berg (Unlicensed), @Amanda BenDor (Unlicensed), Chris Seebregts (Jembi), Steven Macharia (Bahmni) 

Description: Digital Square, an innovative co-investment global program led by PATH aims to serve as a convener in the digital health community, bringing together practitioners to share their work, lessons learned, and future needs. This helps organizations to work together to implement digital health tools that are adaptable to different countries and contexts, also known as Global Goods. To foster transparency, collaboration and synergy, Digital Square uses an open application platform including community feedback to align investments in digital health systems. The open application process provides a unique opportunity for practitioners to learn key details about, and comment on, each other’s tools and implementation plans. This session will describe the innovative open application process and feature global goods awarded through Digital Square including the OpenLMIS, Community of Practice, OpenCRVS, OpenSRP, and Bahmni.

Digital Square- lives at PATH but is a consortium of donors. They are a funding mechanism, and coordinate digital health investments

Open Proposal process- community feedback from peer review committee and governing board, comments, and create coalitions. Transparent process

Bahmni-open source Hospital Information System (HIS) and EMR; does not require custom software development; about 50 implementation

Jembi- OpenCRVS (civil registration and vital statistics); register children, deaths, big unmet need; works with FHIR 7, HopenHIE, and DHIS2. Supports OpenHIE architecture; can interoperate with low demand service like civil registry, with a low demand service like vaccination

OpenSRP- focus in care at facility and community level. Integrates with national health systems like DHIS2. Does Client ID, client management. OpenSRP community   Canopy reporting stack is result of DigitalSquare investment

?What are challenges with Digital Square open proposal process?

• Benefits- standards are valued, collaboration with other open source is encouraged. Peer review was helpful. Digital Square has been helpful for some in terms of opening up other funding too. Organizations appreciate the validation as a ‘global good’.

• Challenges- it is a new process; smaller communities might have trouble keeping up with the administrative lift. Sometimes the amount of money is now known, so that can cause confusion and is hard to plan for. Some organizations don’t necessarily want the proposal process to be so open (don’t want to share their idea).

• Can be a lot of work for not a lot of money

• Amanda’s role is to ensure process is clear, easy for participants. Have to divvy up the pot of funds to spread across multiple global goods

• 5 million dollars invested in 27 global goods initially, went up to 12 million

• Global health funding in general is not directed toward developing core technology. This funding model is better than giving directly to the implementers to decide what to do with it . Longer-term funding can be a gap

• How to harmonize what you are doing at the program level, and balance it with global goods- make it easier for people to build into the health eco system

• Fragmented donors and fragmented funding can make it hard to develop global goods, Digital Square and DIAL are easing that situation

• There is no business model to sustain things -like having a product manager. Its important to think about blocking off specific capacity

• Could think about building in some mechanisms for countries/implementations to pay a licensing fee of some kind. This could encourage sustainability to fund ongoing maintenance of the global good. Software is a ‘leaky boat’ that always needs care

• Suggested improvements for proposal process: support for intellectual property and general community building, also the other ‘soft’ thing around OpenSource. People tend to volunteer for actual coding, other things such as management, not so much

•  

  • Suggested investment in Dev ops-

  • Connect-a-thon and other capacity building to teach about FHIR and standards

Presenters: Wendy Bomett (JSI Zambia), @Chris Opit (Unlicensed) (JSI Zambia)

Attendee: Mary Jo Kochendorfer

• Provided highlights of the implementation of eLMIS and Facility edition.

• Wendy went over the business processes.

•  

  • Receiving

  • Inventory management

  • Dispensing

• Chris will talk about the impact of an electronic systems. Emphasized the importance of having manual systems in place prior to rolling out the electronic system.

•  

  • Automated reports generated from electronic systems

  • Reduction in workload at SDP and Central level (no specific figures showed)

  • Improved efficiency and accountability (due to increased in reporting rates)

  • Commodity availability - before the system they can see what facilities have overstocked items to “share” while awaiting their consignment

  • Timeliness (78% fully automated 66% that are not fully automated)

• Workload decentralization has helped with data entry workload

•  

  • District facilities still have the most workload but central is down to zero.

• Improved Data use

•  

  • Tracked of number of sessions (not sure if they mean login sessions)

• Improved report timeliness by targeted training and championing. Having a system itself can only improve so much. Still needs training and human prioritization.

• Reduced wastage: eLMIS cuts expired drug inventory in hospitals.

•  

  • Uses the system each monday to check the stock status to know if they have overstocked items and can redistribute. Showed a graph of reduction in ARVs (from 1.5% - 0.2%)

• DEMO

  • Select the product source, program area, Dispatch Number (from the dispatch Note)

  • Select each product and batch information

  •  

    • Allow for entering in their own batch numbers

  • Then shows the stock control card which can be printed.

  • Select date, program and receiving node, person

  • Issue voucher is generated for printing

  • Select program area

  • Have to add each product one by one

  • Quantities and remarks.

  • Client ID, Gender, DOB

  • Seemed to only be for ARV clients

  • Goal is to dispense in under 1 minute

  • They enter the number of days needed for the medication. The system says how many bottles.

  • Subsequently, the daily registry is updated.

•  

  • Facility Edition - the web version was showcased.

  • Received products

  • Issue to the dispensary

  • Adjustments

  • Physical Count

  • Dispense (doing a bulk upload from the EHR)

• Discussion:

Zambia is looking to automate down to the community level.

•  

  • What electronic systems do you use for supply chain management in your country?

  • What are your pain points?

• Questions:

  • Started work on that. Collaboration is very difficult. Interface is working in two - three more facilities. Now are testing the web-enabled version of facility edition.

  • Chris: yes… but didn’t clarify and mentioned paying attention to security

  • Wendy: yes. Needs to rolled out by the government. No report no product principle helps move to systems.

  • Data quality and completeness. There are data validations built into the system so it is harder to “quickly submit” anything. You have to true up things.

  • Chris: big issue. When we developed the training program, we looked at sustainability. How to continue without us re-training? We train people on the job (hands-on training). If you go to the facility, you can train everyone in the facility. Facility then takes over in training interns and new people.  District health information officers will also train facilities.

  • Wendy: there is an e-learning module for them to print out a certificate. Annual meetings to discuss the data and will hold a training on the 3rd day or something.

  • Wendy: we have a report who can look at the adjustments which HFs are making. Particularly with facilities that are automated the entire way.

  • LAN FE system

  • They wouldn’t abandon because built on manual processes

  • Sustainability plan for the ministry to own.

  • Everyone wants something to track transactions. Phones won’t work because everyone has at least 100 products.

•  

  • Have you automated pharmacy dispensation?

  • Are you interoperable with SmartCare? (from CDC - Dan Rossen)

  • Are you following OpenHIE principles?

  • Did we face transparency challenges?

  • Challenges with uptake of the system at the facility level?

  • Sometimes HF report on time but then they have to go back and resubmit?

  • Who owns the data?

  • MSH Question: you many facilities … how do you manage staff turnover/attrition and training?

  • WHO Humphrey Question: Issue with leakages (paper and what is on the ground discrepancies). Are there issues with redistribution (which allows for more opportunities for leakages).

  • WHO Question: What about internet access?

  • If JSI was to walk out today, would the system still be used?

  • Question: For low-throughput clinics, have you thought about using mobile?

• A system should be there to help a ministry not lose money

Attendees: Rebecca, Swetha, Mary Jo

• Emphasis from CDC and USAID on the importance of them shifting from supporting bespoke tools to self-reliant tools and Global Goods

• GIZ mentioned Digital Square and DIAL as platforms that they would be interested in leveraging

• In order for donors to follow these principles, countries actually need to have a digital health strategy. So there is a call to countries to create these plans in order to get funding in this area

Attendee: @Swetha Srinath (Unlicensed)

Speakers: Maryanne Mureithi; Jamil Zaman (Bangladesh), Ephrem Lemango

Moderator: Uju Aderemi

1. Medic Mobile [Ethiopia]

• Focus of intervention:

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  • Care coordination / referral network

• Overview:

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  • Community health innovation network – partnership with living goods

  • Integrate community activities – health facility care

  • Increasing reach through technology

• Why Referral

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  • High priority cases

  • Time-sensitive

  • Closing the loop

• Referral pain points

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  • Lack of referral tools / loss of tools  [paper systems – supply chain]

  • Accuracy of reporting

  • Px / Patient experience [long lines]

• MVP Design

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  • Digitized referral systems

  • Referrals trigger tasks

  • Referral targets

  • Facilitating communication

• Challenges

•  

  • Internet communication issue

  • Performance of app

  • Keeping the workers engaged

  • Involved them in design process

1. Mobile Job Aid for H.E.Ws [Ethiopia]

• Focus of ppt:

•  

  • RMNCH

• Overview

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  • Health Extension Program

  • Intro: HEP is one of the strategies adopted by the government of Ethiopia to achieve universal coverage of primary health care among rural population

  • Goal: to create a healthy society and to reduce maternal and child morbidity and mortality rates.

  • Overview: Program that is deeply rooted in communities, providing primary level preventive activities to household members. In addition to community activities, HEP also provides health post–based basic services, including preventive health services such as immunizations and injectable contraceptives, and limited basic curative services such as first aid and treatment of malaria, intestinal parasites, and other ailments. Case referral to health centers (HCs) is also provided when more complicated care is needed.

• Why Mobile?

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  • Coverage / equitable coverage

  • Timeliness of visits / care

• Components of tool

•  

  • Automated  reminders and follow up

  • Mobile job aids

  • Leading to improved referral work flow
    
    
    

• App points of intervention

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  • HEW interaction with client: ANC 1 – ANC 4

  • ANC 1 – sent to health center for first one, then sent back to community

  • 2nd, 3rd, 4th sent to community / HEW

  • After delivery, HEW notified to provide post-natal care

• HEW Application

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  • Provides info on location where visit should take place

  • Provides timeline for timeliness of visit

  • Provides referral management etc.
    
    
    

• Status / Progress

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  • Issues: Capture at health facility level when delivery happens – needs to improve

  • Political commitment: Needs to start from minister level

  • Risk: Intermittent inaccessibility / increasing technical complexity / changing and expanding vision and scope
    
    
    

1. eMIS (Save the Children Bangladesh)

• Focus of intervention:

•  

  • eMIS

• Partnership:

•  

  • MOHFW

• Problem

  • Included supervision, though cumbersome: Paper-based system included a supervision process to ensure that FWAs and HAs were visiting the households and correctly completing the forms, but it was cumbersome to
    Supervisor role: Supervisors required to visit the households or satellite clinic that the HAs and FWAs supported to verify the data collected and to review the registers and reports.

  • Lack of supervisor feedback: Under the paper system, FWAs and HAs did not receive direct feedback on their performance in completing the required forms

  • Data use not regular: Under the paper-based system, FWAs, HAs, and supervisors did not regularly use the data they collected to improve quality and coverage of services. The information collected was primarily reported to the higher level,

  • Only option for referral: The only way to know whether a client completed a referral was through self-reporting during follow-up visits, which could be occur between two and four months after the initial visit. Facilities to which the clients were referred did not necessarily keep records of referrals, and the reporting mechanisms for referrals were weak.

•  

  • Inability to track patient along continuum of care

  • Reporting delay / slow and error prone

  • Lack of sync

  • Paper-based system

• Digital Application – eMIS

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  • Registers needed to be unified / simplified (across continuum of care)

  • Indicators (for appropriate stage) included

• Digitization process

  • Client unique identity – pregnancy registration

  • Provides prompts and alerts based on protocol

  • Protocol embedded into the tool

  • Longitudinal health records

  • Stratify clients by risk type

  • Schedule work plan for providers

  • Monitor performance of healthcare provider  

  • Assess health facilities

  • Manage health commodity inventory

  • Data Services  

  •  

    • Non routine data collection

    • Automated analysis to generate new information

    • Map location of facilities

  • Reduced workload of HAs and FWAs: eMIS has significantly reduced the workload of HAs and FWAs and errors that were related to transcribing the data to different paper forms.

  • Time spent compiling info: When using the paper-based system, FWAs and HAs would spend one to two days each month compiling the monthly HIS report. With the eMIS, they can press a button and the report is generated instantly.

  • Better tracking of patients: Unique health identification system (master client index) established in the eMIS through a population registration system has improved quality of care by allowing health workers to track individuals over time and ensure the continuum of care  At the facility level, service providers can pull up an individual’s information by using the unique health ID and retrieve all stored data from the population and service databases. FWAs and HAs can also retrieve services provided to their clients as well as check on referrals using their tablets with the unique health ID.

  • Service mapping: Dashboards generated from the data collected on the tablets have helped district and national-level managers plan services to ensure the continuum of care. A manager can pull up services by a particular provider to view data by date. This reduces the need for supervisors to travel to the field to check all aspects of quality of care to determine where improvements are needed.

•  

  • 1. Provider System

  • 2. Health System Managers

  • Results with eMIS

1. Questions

• Was paper replaced in Bangladesh?

•  

  • Double reporting – in initial stages; when reliance on digital increased, paper was replaced in Bangladesh

  • 2-3 months lead time: for HCPs to get used to smart phones

• Are these tablets in Bangladesh / Ethiopia – real time offline?

•  

  • Ethiopia: moving towards tablets, which should work offline

  • Bangladesh: All data is continuously synching – when internet is available, synch happens in background

  • OpenSRP for case management – how to make sure you refer without duplication

  • CHWs refer patients within app  when activities initiated, they have to go through app to trigger referrals  all activities are coordinated using the platform, and CHW has to be registered

• Data Privacy?

•  

  • If we want to check if follow-up is done, we only display CHW performance, as opposed to patient status / data

  • Bangladesh: govt doesn’t have legal framework RE: data privacy – working with govt based on paper based privacy policy – a) Also patient identity based on number, not patient name pre-referral and b) data only becomes available to next level provider IF patient is referred.

• Linkage to EMR

•  

  • CHWs refer patients within app  when activities initiated, they have to go through app to trigger referrals  all activities are coordinated using the platform, and CHW has to be registered

  • CHW Registering – at health facility + community?  

  • CHWs – “hashing”? non deterministic

• eReferral – patient level challenges – any cases of where patients referred but they didn’t show up?

•  

  • Digital solutions are not the only solutions

  • This platform encourages continued community worker – persistence – ensures patients get care

Attendee: Vidya

Panelists: Garret Mehl, Tigest Tamrat, and Smisha Agarwal

Notes:

PATH, as the support org to WHO, convened a session with the WHO team that has put together the very first WHO Guidelines on Digital Health Interventions for HSS.

Team consists of Garret Mehl, Tigest Tamrat, and Maeghan Orton (latter two involved with early CCPF work)

The guidelines for formally approved by WHO board this week and will be made publically available early next year. PATH is helping put together an interactive website to accompany the print publication. The guidelines will also have helpful language/visuals to show how these interventions map to Universal Health Coverage (UHC) goals.

This work is part of the larger Digital Health Atlas compendium that this team is also leading (a WHO global technology registry platform).

The team first developed "Classification of  Digital Health Interventions" and the Guidelines map to this classification.

The third deliverable is a "Planning and Costing Guide for Digital Health Interventions" which is set for release next Spring.

Monitoring and Evaluation of existing digital health interventions:

The team highlighted the usefulness of the mERA checklist which has been around for a couple of years now. For impact evaluations, they recommend the following study designs:

Controlled before and after;

Stepped wedge RCT;

Interrupted time series studies

More information on mERA here:

https://www.bmj.com/content/352/bmj.i1174 (paper summary)

https://www.researchgate.net/profile/Amnesty_Lefevre/publication/311738723_Monitoring_and_evaluating_digital_health_interventions_a_practical_guide_to_conducting_research_and_assessment/links/5858cdf908ae64cb3d47f7d3/Monitoring-and-evaluating-digital-health-interventions-a-practical-guide-to-conducting-research-and-assessment.pdf (detailed assessment guide including the checklist)

Takeaways:

• OpenLMIS should start folding in language about both principles of digital development as well as the Digital Health Interventions classification and guidelines in our future proposals and when talking about our current work.

• Tie efforts to UHC when possible

• OpenLMIS team (see follow-up/action section) is in touch with the WHO team about how to include the Implementation Toolkit in the interactive website that PATH is working on.

• Reference the mERA assessment guide for future digital health work

Attendee: Rebecca

Online self-administered screening tool for improving TB detection among students in Ethiopia (MSH)

• In Ethiopia, they have case-finding issues. ⅓ cases are undiagnosed. Targeting universities. Students were active partners in the initiative , made suggestions on how to implement, draft the self-screening checklist, and how do outreach, etc.

Online screening to be the first layer of assessment (rather than needing a HCW to examine each individual)

• The tool linked with CommCare for those whose screening showed suspected TB

• Targeted students on a free wifi system that they were already using (good use of resources); did targeted outreach in free wifi hotspots

Maternal Health in Liberia(D-Tree)

• Want flexibility to attend different health facilities throughout pregnancy/delivery

• About 80% of facilities in Monrovia are private. How do you adopt across a lot of actors; public and private. This can act as a central repository of data that bridges the public/private gap

Tuberculosis in Thailand (D-Tree)

• Migrant populations tend to lose touch with health system and default on