Field Report: Our recent experiences

The Health Extension Workers (HEWs) in our maternal healthcare project have now been using the smartphones for almost 6 months, so we’re starting to build up a really good picture about what works and where there are issues. Most of the information here is based on field reports Araya has been sending back following the training sessions he has been running and follow up discussions with the HEWs.

For the last 2 months (since mid-November), the HEWs have been using the phones for recording real patient encounters, previously they were submitting test data, whilst they got used to the phones and protocols. We now have around 200 patient encounters recorded from 10 HEWs and 2 Midwives, including 12 delivery records.

The feedback we have received from the HEWs and midwives has been very positive. They seem most comfortable using the Tigrinyan versions of the protocols, HEWs can switch between English and Tigrinyan and are free to enter text data in either Latin or Ge’ez script, although very few questions require any text input. The HEWs and mothers seem very happy with using the protocols, as it checks that all the right questions are being asked during the patient encounter.

From a technical point of view, the phones are working well. There are some times when the GPRS connection is poor, so the HEWs are unable to submit the records immediately, but they are able to once the connection is restored a day or so later. We don’t seem to have had any major problems regarding recharging of the phones, although some HEWs have commented that battery life can be poor.

The main issues we have come up against so far are:
Patient Identification. This was always going to be an issue, since there isn’t a standard regional/national patient record number we can readily use. Each Health Post records patient visits in a log book and the patient id is simply the number of the next row in their log book. To try to save confusion between patients having different references in the log book and the electronic protocols, we are identifying patients by a combination of the health post name and the id from the log book – which also makes it easier to cross-reference between the two systems. Unfortunately we are getting a number of cases where patient id numbers are being entered on the protocols inconsistently or incorrectly. This may cause a visit record to be recorded against a non-existent patient registration, or, worse, against the wrong patient. However we are recording the patient age and year of birth on every protocol form submitted, so this helps to identify where errors may have occurred, but would be good to try to stop this happening in the first place. We are looking at a variety of ways in which we can resolve this, for example barcodes or fingerprints, but none of these are easy to implement.

Length of Visits. Some HEWs have mentioned that using the protocols takes a long time. I think it was always likely that the protocol forms would increase the time for a patient encounter. Not necessarily solely due to the technology, but also because we are asking them to ask quite a comprehensive set of questions and a physical examination. Previously, without the electronic protocols, the patient encounters may not have been as thorough.
From the start/end times (automatically logged by the phones) we can identify roughly how long an ante-natal care visit takes a HEW to complete, for an ante-natal care first visit the average time for the patient encounter is around 20 minutes

HEW engagement. We have a wide disparity in the number of visit records being entered by different HEWs. Some are recording visits regularly, whereas others have hardly entered any. We are looking in to the reasons for this and how we can encourage those who aren’t participating to take a more active role. There are many possible reasons for this, perhaps technical issues, not understanding what advantages using the protocols may bring, or that they have been out of post on other training.

Over the coming few weeks we hope to find ways in which we can address these issues.

Developing an Analytics Dashboard for Maternal Care

Over the last few months, alongside the protocol forms the Health Extension Workers (HEWs) are using to record maternal care patient encounters on their smartphones, we have been developing an analytics dashboard to allow HEWs, midwives, their supervisors and the local health bureaus to track the progress of pregnant mothers, their medical & pregnancy risk factors, and a range of key performance indicators.

Providing information back to HEWs and their supervisors about their performance, we hope will help to increase the number of ANC visits according to the recommended schedule, and provide information for local health bureaus to better prioritize resources and training. The current performance indicators include the percentage of ANC visits made on time, number of protocols submitted, PNC visit made on time and immunization records for both mother and baby.

Analytics Scorecard home page

For the HEWs, we can also provide information about the upcoming appointments, deliveries to assist them to plan their time better. Guidelines from the Ethiopian Ministry of Health encourage all pregnant mothers to give birth at local health centres, so we can use the ANC visit information to inform local midwives on expected delivery dates. Local health bureaus and HEW supervisors are able to compare the performance between different health posts or districts.

We are trying to be careful that this doesn’t become used as a EMRS (electronic medical records system) – there are already plenty of MRS’s available – rather we are looking at ways in which the HEWs can see advantages to recording their patient visits on their smartphones, by providing them with relevant, timely and easy to understand information about the patients in their area. In the future we may look at how to integrate with an MRS system (e.g. OpenMRS), but currently this is not the focus of what we’re trying to achieve.

For the technically minded, the analytics dashboard runs by accessing the ODK Aggregate database directly. We’ve looked at several different data collection tools (especially those focused on medical information collection), but all would require either direct database access (as we have done with ODK) or extraction of the data via an API (which would generally mean exporting to another database then accessing the dashboard from this). We’re still in the process of getting the HEWs and their supervisors up and running with accessing all this information via the web application and smartphone – we also still have some development work to do. Currently our researchers in Mekelle are printing regular reports to give to supervisors and HEWs, also, as this is a research project, it’s important that all the information (from protocols) can be stored as a hard-copy with the rest of the normal patient records at the health posts.

We’re currently developing an application so HEWs are able to access their task/performance information directly on the smartphones – which will work offline when there is no GPRS connection available, and update automatically when a connection is available (most likely using an HTML5 application, rather than a specific Android application)

Screen shots from prototype mobile browser version (personal data has been pixelated)

Using a smartphone platform to deliver this type of information is a good balance & compromise between other platform choices we could have made. Using PCs/laptops/netbooks would involve much more technical support, training and maintenance, and likely to have other issues such as access to electricity, portability etc. Smaller, low-spec phones would not allow us to present the information in such a clear and easy-to-use way.

For those interested the code for the analytics dashboard is available to download from GitHub at: https://github.com/alexlittle/Digital-Campus-Analytics

Protocol Forms

For those interested in the protocols forms we’re using for the maternal care project you can now access these on GitHub, see: https://github.com/DigitalCampus/Digital-Campus-Protocols. These are the forms that the Health Extension Workers are using (with ODK) to manage their maternal care visits. Please feel free to reuse these forms for your project, they’re released under a creative commons license. Over the coming days we’ll post up some more information about how to use these forms and some of the other developments we’ve been working on.

I’ve also posted up the code for our Ethiopian Pregnancy Calculator Android app (code and info) and the Amharic/Ge’ez keyboard (code and info)

Mobile Developer Challenge

Win an HTC Hero smartphone by taking part in our Mobile Development Challenge

Create an Android application to maintain a task/appointment list for Health Extension Workers on their smartphones to help them manage their maternal care visits.

Closing date: Saturday 18th February 2012

Requirements:

  • Needs to work with Android v2.2 and above.
  • Stores the task data offline, connecting to the server to update the task list regularly. Update [20 Jan 2012]: Just to clarify, following a couple of queries, there is no requirement for the application to submit data back to the server, the task list is generated from information submitted by the HEws using OpenDataKit regarding their patient visits.
  • The task list will require a username and password (as get or post parameters) and will be provided by the server in JSON format. This is an example of the structure of the data that will be returned by the server, you can use this link to test your application – this is the format your application will be judged against.
  • Code must be released under an open source license and made available on a publicly accessible code sharing site (for example Sourceforge, GitHub, Google Code)

Criteria:

  • Your application must meet all the requirements to be eligible for the prize.
  • You must be an Ethiopian national, currently living in Ethiopia, to be eligible to enter.
  • Your mobile application will be judged on:
    • code structure, quality, error handling and commenting
    • user interface design
    • features available (for example: highlighting overdue tasks, grouping by task type etc)
  • All code submitted must be original and your own work.
  • The judges decision is final.

Help to get started:
If you are new to developing applications for Android, here are some links to help get you started:

How to submit your application:
When you have completed your application, email the application package (.apk) file to alex@digital-campus.org with the following information:

  • Your name
  • Your employment/educational status (where do you work/study)
  • Contact details (email, phone/skype, website, address)
  • Url to where you have published your code.

For more information please contact: alex@digital-campus.org

Download a poster for the challenge to display in your organisation.

mQuiz: smartphone based assessment activities

Over the last few weeks, we’ve been looking at how we can deliver assessment and quiz activities on smartphones. The main requirements being that users can take the assessment activities offline on their phones, but the results can be submitted back, so we can track progress and results. We now have a prototype system available for anyone to try out: http://mquiz.org. The video below shows the client application in use:

Using mQuiz you can either create a quiz online, or you can import quizzes in the GIFT format. This format is used by Moodle, so if you have an existing quiz in Moodle you can export in GIFT format for importing into mQuiz, it will support multiple choice, multiple select, short answer, matching and numerical question types. Anyone can then take your quiz using their Android smartphone and results can be sent back to the mQuiz website for you to track responses.

We’re looking to create a more generic client application (probably HTML5) to enable running on a wider variety of platforms. All the code (both server and client) is open source, so you can even create your own mQuiz server or adapt the client, for more info see the developer page: http://mquiz.org/developer/.

Any feedback welcome 🙂

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