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Improving Quality and Access Through the Use of Electronic Protocols. Bringing evidence-based medicine to frontline health workers worldwide. www.d-tree.org. Our Vision . . . . . . is to provide health workers with the tools they need to deliver this care worldwide.

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  1. Improving Quality and Access Through the Use of Electronic Protocols Bringing evidence-based medicine to frontline health workers worldwide www.d-tree.org

  2. Our Vision . . . . . . is to provide health workers with the tools they need to deliver this care worldwide . . . is a world in which every person has access to high quality healthcare Our Mission . . .

  3. We provide • Support to clinic staff • antenatal • peripartum care • neonatal + child care • HIV/AIDS • chronic disease Linked through mobile phones • Support to CHW • FP and antenatal care • neonatal screening • client support + referrals

  4. What we do • Develop or adapt clinical protocols that enable task shifting • Validate protocol effectiveness to ensure quality of care • Design open-source software to support scale up and correct use of protocols • Improve decision making by making data available at and across points of care

  5. How sick? very □ mild □ well □ Symptoms fever □ RR > 40/50 or chest indrawing □ diarrhea □ abd. pain □ rash □ Emergency? unconscious □ bleeding □ seizure □ other □ next  next  Treat Fever NOW Symptoms REFER URGENTLY getting sicker □ neck stiff/headache □ ear pain □ urine cloudy or pain □ sore throat □ no source found □ ampicillin 500 mg+ ALu 1 tab+ paracetemol 1 tab+ fluids next  next  1. Develop or adapt clinical protocols   Bringing evidence-based medicine to frontline health workers worldwide next  

  6. AIDS study: South Africa 2. Validate protocol effectiveness = evidence base 24 minor problems 4 significant problems Mitchell, M, “Improving Care – Improving Access: The Use of Electronic Decision Support in AIDS patients in South Africa” Int. J. Healthcare Technology and Management, Vol. 10, No. 3, 2009

  7. 3. Design open-source software to support scale up and correct use of protocols

  8. PC data link 4. Make data available at the point of care Performance Report existing patient database patients lost to f/u 1. ali samuel 2. ben hasan 3. etc. Enable continuum of care • growth monitoring • immunizations • lab tests • pregnancy registration • referral tracking

  9. South AfricaHIV Mobile Decision SupportTanzania Mobile E-IMCI Specific Applications

  10. Child Health e-IMCI

  11. INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS A set of clinical algorithms to assess, classify and treat children 0-60 months of age for • Diarrheal Disease • Pneumonia • Malaria • Malnutrition • Ear infections • Immunizations

  12. INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

  13. INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

  14. Adherence improved Training time 30 mins. Can we improve quality by provider? DeRenzi, B., Lesh, N., Parikh, T.S., Sims, C., Mitchell, M., Maokola, W., Chemba, M., Hamisi, Y., Schellenberg, D., and Borriello, G. e- IMCI: Improving Pediatric Health Care in Low-Income Countries. ACM Conference on Computer-Human Interaction (CHI), April 5-10, 2008, Florence, Italy.

  15. Can we improve quality by provider? What did mothers say about eIMCI? “In the past the doctor used to write prescriptions on a piece of paper without asking us questions, but today we were asked questions. That is what was different.” “I was very happy with the new instrument. Previously we were not provided good services …the doctor used to ask what was wrong and then prescribe “chloroquin” and “panadol” for the child without even examining the child … He did not like to listen to me and would write the prescription before I could finish telling him the problem with my child.” “What I liked the most was the way we were asked questions, the way my child was examined, and how they handled my child by touching some parts of his body to learn what the real problem is.” “The service was like past services because my child was given “dawa mseto” as usual, but this time we were asked some questions.” translated from Swahili

  16. Can we improve quality by provider? What did providers say about eIMCI? “I can see that the instrument is good as it helps me to do IMCI both faster and with the proper procedures.” “I liked it because it explains the situation of the child well and reminds you of things you can’t remember on the forms.” “The thing I like most about using the PDA is that it is simple to calculate dosage. A thing that I don’t like is that there are diagnoses that are not in the PDA, such as UTI, HIV, that should be added, because there are now more childhood illnesses.” “It simplifies work and provides direct results. It is different than paper, where you have to make the decisions. The PDA makes its own decision, and will tell you if medicine is necessary and what the dosage is, so you can’t make a mistake in treating a child. The PDA makes the parents interested and they see that the doctor is listening carefully. The [paper] forms are difficult to use but the PDA is simple.” translated from Swahili

  17. Can we make improve the protocols? = Fever  RDT  treat if + look for other source if negative

  18. provider adherence patient adherence correct assessment and treatment of patient correct treatment instructions and advice understanding of treatment instructions and advice correct treatment and care given positive health outcome Can we improve comprehension by client? National Institutes of Health (USA) 2009-2011 n = 5000; 20 sites Does the use of electronic protocols running on mobile technology at the point of care improve the patient adherence to the prescribed treatment and follow-up plans given in the IMCI protocols? Does improved adherence by the patient/caregiver to treatment instructions and follow-up advice lead to an improvement in health outcomes?

  19. Can we bring IMCI to the community? “[There is] an estimated shortage of almost 4.3 million doctors, midwives, nurses and support workers worldwide.” World Health Report 2006 WARNING: Talk with mother about child feeding       In Tanzania, many people walk over 5 miles to reach the local health center

  20. Maternal and Neonatal Care “The core principle underlying maternal, newborn and child health programmes should be the continuum of care…in the lifecycle and from the home…to the health centre and hospital” WHO/UNICEF joint statement on newborn survival, 2009

  21. Maternal Care At the Community Level • Protocols for CHW for • Client Registration • Home based care • Antenatal screening and advice • Bednet, IPT, iron, folate • Neonatal screening • Family Planning • Referrals • Home delivery – plan B

  22. Maternal Care At the Clinic Level • Protocols for nurse/midwife for • Client registration • Recording lab, weight, BP • Antenatal care and counseling • PMTCT • Labor and delivery • Post partum care • Referral to CWH

  23. Neonatal Care At the Clinic Level • Protocols for • routine care for newborns • emergency care for newborns • APGAR scoring • IMCI < 2 weeks of age At the Community Level • Protocols for CHW for • well baby care • neonatal screening • emergency care • referrals

  24. CommCare for Community Health Workers

  25. CommCare for Community Health Workers • Client registration and f/u • Support of AIDS patients • Antenatal care • Neonatal screening • Community IMCI • Family planning

  26. CommCare for Community Health Workers From paper focus To client focus

  27. What we have learned • The use of standards of care/clinical protocols can improve quality of care and health outcomes if used correctly. • Electronic protocols facilitate correct use. • Most currently used protocols have not been rigorously validated in clinical trials. • Both clients and providers seem to like the use of electronic protocols.

  28. What we have learned • Health workers including CHW can quickly learn to use mobile phone based protocols. • Protocol and software development is best done in an iterative process and is very labor intensive. Protocols developed by experts do not always work as expected. • The ability to link the patient record across multiple locations and visits is an important contribution to quality of care.

  29. We are now working in the areas of: reproductive health chronic disease child health preventive care • HIV/AIDS • Diabetes • Hypertension • TB • antenatal • family plan. • labor + del. • newborn • IMCI • malaria • newborn • HIV/AIDS • antenatal • immunizations • care and support

  30. With funding from: UNICEF Bill and Melinda Gates Foundation CARE National Institutes of Health The UN Foundation The World Health Organization The Swiss Tropical Institute The Rockefeller Foundation International Development Research Ctr. Harvard University Program on AIDS Microsoft Research Pathfinder International Centers for Disease Control

  31. Improving Quality and Access Through the Use of Electronic Protocols Bringing evidence-based medicine to frontline health workers worldwide www.d-tree.org

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