E-Referral System: Materna Health in Mumbai, India


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E-Referral System: Materna Health in Mumbai, India

  1. 1.                                           E-Referral Systems for Maternal Health     Mumbai, India         Health Information Systems to Improve Quality of Care in Resource Poor Settings May 13, 2011 Presented by: Rachel Koffman Crystal Lawrence Tseli Mohammed S a n a   |   P a r t n e r s   i n   H e a l t h |   M I T   O p e n C o u r s e W a r e  H e l l e r   S c h o o l   f o r   S o c i a l   P o l i c y   a n d   M a n a g e m e n t ,   B r a n d e i s   U n i v e r s i t y  
  2. 2. E-Referral Systems for Maternal Health | Mumbai, India  Initial Problem There are great disparities in the provision and access to maternalhealthcare worldwide, most often attributed to differences in socioeconomicfactors. This issue is most apparent in the divide between standards of maternalhealth between the developed and developing world. Developing countriesaccount for 99% of all maternal deaths, as over a thousand women die dailyfrom preventable complications during pregnancy and childbirth.1 Latest estimates reveal that in the developed world, the maternalmortality ratio2 (MMR) was estimated at 14 per 100,000 births, whilst indeveloping regions, it was estimated at 290 per 100,000 births (2008)3. Thoughthis demonstrated gap, related to access to care and information, poverty, andsociocultural norms and practices, has been declining (2.3% per year1). India, a country with one of the fastest growing economies today, hashad a similar decline in its MMR over time, yet in its most populous city, Mumbaithis is not the case. The MMR of Mumbai has been estimated to he as high as450 deaths per 100,000 births4. “…in the heart of Mumbai last year over 200 women died at childbirth beating the figure of 154 last year. This shows how maternal mortality in the city is rising at an alarming pace each year.” (February, 2011)5 One suggested mechanism to help mitigate this rising issue in Mumbai, isthe development and implementation of an e-referral system, to efficiently andeffectively link primary level maternal healthcare to appropriate secondary andtertiary level care when necessary.                                                                                                                1  World  Health  Organization.  Maternal  Health  Factsheet.  November  2010.  Retrieved  from:  http://www.who.int/mediacentre/factsheets/fs348/en/index.html  2  Maternal  Mortality  Ratio  is  defined  as  “the  number  of  maternal  deaths  in  a  population  divided  by  the  number  of  live  births.  It  depicts  the  risk  of  maternal  death  relative  to  the  number  of  live  births.”  (WHO)  2008.    3  WHO,  UNICEF,  UNFPA  and  the  World  Bank.  Trends  in  Maternal  Mortality:  1990-­‐2008.  Retrieved  from:  http://www.who.int/reproductivehealth/publications/monitoring/9789241500265/en/index.html    Society  for  Nutrition,  Education  and  Health  Action.  Retrieved  from:  http://www.snehamumbai.org/index.php  4  New  Delhi  Television  (ndtv.com):  News.  Mumbai’s  Rising  Maternal  Mortality  Rate.  Retrieved  from:    5 | Health Information Systems to Improve Quality of Care in Resource Poor Settings | 2
  3. 3. E-Referral Systems for Maternal Health | Mumbai, India   Within the current maternal healthcare system of Mumbai, there are a fewissues specific to the contextual setting and acceptable standard procedures:• Lack of coordination between primary, secondary and tertiary care: o Patients often referred to tertiary, skipping secondary care, even if appropriate. o Results in bottlenecks at tertiary care, and unused secondary care. o Providers lack expertise and confidence to refer to secondary care (sociocultural issues within primary care organizations).• Inefficient and ineffective patient tracking – within each and amongst the three different levels of care.• Lack of patient follow-up after referral. An integrated e-referral system that connects the three levels of maternalhealthcare can target these challenges of the current system, improvingcommunication and coordination between the varying levels. The system wouldnot only increase efficiency and improves competencies, but also reducemismanagement of paper records, and improves legibility of clinical notes.Additionally, it doubles as a form of electronic data collection, which can beused for monitoring and evaluation purposes and inform futurerecommendations for the system.Background Maternal mortality and morbidity is a severe and prevalent problem inIndia. The maternal mortality ratio estimated at 500 per 100,000 live births is asmuch as fifty times higher than many developing countries and six times higherthan neighboring developing country, Sri Lanka6. Causes of maternal death inorder of most prevalent are hemorrhage, infection, hypertension, andobstructed delivery. Maternal mortality in India accounts for 25% of all maternaldeath worldwide7.                                                                                                                6  Pachauri,  Saroj.  Defining  a  Reproductive  Health  Package  for  India:  A  Proposed  Framework  7  Goldie  SJ,    Sweet  S,    Carvalho  N,    Natchu  UCM,    Hu  D,  2010  Alternative  Strategies  to  Reduce  Maternal  Mortality  in  India:  A  Cost-­‐Effectiveness  Analysis   | Health Information Systems to Improve Quality of Care in Resource Poor Settings | 3
  4. 4. E-Referral Systems for Maternal Health | Mumbai, India   In order to meet Millennium Development Goal 5 there needs to be aglobal reduction in maternal mortality of 5% annually. Between 1990 and 2005,global maternal deaths decreased by only 1%; in India, the decrease inmaternal deaths between 1990 and 2005 was about 1.8%. Mumbai, India, has a population of approximately 12.5 Million. The mostpopulous city in India, it is also generally accepted as the richest, with thehighest GDP in the country. The densely populated, urbanized city has anaverage of literacy rate 89.7%, higher than the national average of 71.7%8. The city has vast and robust healthcare infrastructure, with specificfacilities and providers in place to supply maternal healthcare services:• 3 tertiary hospitals (also medical colleges)• 13 peripheral hospitals with maternity wards• 25 maternity hospitals• 167 health posts - primary health centers in slums• 150 dispensaries Although more than 95% women register in theantenatal period, almost 50% of those women visit a hospitalfor the first time in the last three months of their pregnancy.Additionally, although 91% of pregnant women deliver inhospitals, almost one-third of them arrive on average onlyhalf an hour before delivery. From this, we can imply that insuch circumstances, there is little time to diagnose andrespond to any preventable complications that may arise. “Public infrastructure is often sub-optimally utilized. It is the product of a range of interrelated factors such as… , poor referral systems.., attitudinal and management challenges, inappropriateness and inefficiency of data management systems.”9                                                                                                                8  Census  of  India,  2001.  Basic  Data  Sheet:  District  Mumbai  and  Mumbai  (Suburban)  Retrieved  from:  http://www.censusindia.gov.in/Tables_Published/Basic_Data_Sheet.aspx    Society  for  Nutrition  Education  and  Health  Action  (sNEHA).  City  Initiative  for  Newborn  Health,  Mumbai:  Overview  and  Protocol.    Pg  4.    9 | Health Information Systems to Improve Quality of Care in Resource Poor Settings | 4
  5. 5. E-Referral Systems for Maternal Health | Mumbai, India  Pilot System: E-Referral Software for Maternal Health Launched in 2010 Sana MRS Mumbai© is an e-referral, patient trackingsoftware system being piloted by 2 Primary, 1 Secondary and 1 Tertiaryhealthcare facilities. The software aims to improve coordination, tracking, andpatient follow-up between the provider institutions, especially in terms ofmaternal health referrals.System Overview:• Each doctor registers with username and password, needed to securely access the system (screenshot 1).• Primary care doctors complete patient forms (screenshot 2).• Referrals inputted into system when necessary, and referred provider (secondary or tertiary facility) sent automatic notification (screenshot 3).• Patient given information regarding referral, including patient tracking ID #.• Patient tracked to ensure visit to referred provider (screenshot 4). 1 2 3 4 | Health Information Systems to Improve Quality of Care in Resource Poor Settings | 5
  6. 6. E-Referral Systems for Maternal Health | Mumbai, India  Research Our research highlighted the significant problem area of inadequatehealth care for pregnant women both in India and in most developingcountries. The use of referral systems as a way to ensure adequate care oncewomen have access to essential services, when successfully implemented, hasbeen linked to reductions in pregnancy related morbidity and mortality. Often, the most significant problems associated with maternal mortalityoccur before any referral system could have been useful in intervening to helpsave a mother’s life – these are problems associated with access. Much of theliterature suggests that strengthening the health system to create greater accessis the most important tool to combat high maternal mortality rates. However, theimportance of adequate and functioning referral systems are consistentlymentioned as complimentary intervention to garnering health system access.FindingsThe Real Effects of Maternal Mortality and Morbidity Maternal mortality and morbidity has extensive and detrimental effects onfamilies and communities beyond the death and sickness of the mothersthemselves. Effects of high rates of maternal mortality are linked to:• Family disintegration and psychological problems• Economic and social problems in the community and the country• Children exposed to social risk• Increased financial burdens on other family members• Increases in health problems of children, i.e. increased prevalence of childhood diseases, malnutrition, diarrhea etc. | Health Information Systems to Improve Quality of Care in Resource Poor Settings | 6
  7. 7. E-Referral Systems for Maternal Health | Mumbai, India  Referral Systems Worldwide: Room for Improvement Many countries both developing and developed have protocols forreferral systems for obstetric care. These guidelines provide examples of whenwomen should be referred to higher levels of care. Full implementation ofreferral systems worldwide would result in between 30-50% more referrals ofpregnant women to antenatal or delivery care.10 The current global averagesfor referral rates are between 6-12%, and significantly lower in rural areas wherematernal mortality rates are likely to be higher than in urban areas.Significant Issue: The Three Delays Model11 The Three Delays Model gave us an interesting lens through which to viewthe areas for technological intervention in reducing maternal mortality. The firstdelay is defined as a delay in recognition of a health problem and the decisionto seek care. The second delay is related to reaching the appropriate facility,either improper referral or transportation issues. The third delay is in the healthcare actually provided and wait times/understaffing issues once the womanreaches the facility. This model pinpoints the specific areas in need ofintervention to reduce maternal mortality. The pilot referral system in Mumbaicurrently deals mostly with the second delay. If it is furthered to includeconsidering capacity at the partner health centers it could also combatproblems in the third delay arena.Transportation: Referral Systems Main Challenge Research has shown that transportation to referred health centers issignificant barrier to women obtaining the care they should receive. Even with acomputerized referral system in place, such as the Mumbai Pilot project, there isno way of ensuring that the women will end up in her scheduled center for care.                                                                                                                  Albrecht,  Jahn  and  Vincent  De  Brouwere  Referral  in  Pregnancy  and  Childbirth:  Concepts  and  Strategies  10  www.dfid.gov.uk/.../SystematicReviews/FINAL-­‐Q35-­‐Aberdeen_maternal_mortality.pdf  11 | Health Information Systems to Improve Quality of Care in Resource Poor Settings | 7
  8. 8. E-Referral Systems for Maternal Health | Mumbai, India  The literature suggests that adequate referral systems are complemented byimprovements in emergency transport coordination systems.Technology in Referral Systems: Case Study Zambia A report published by Research Triangle Institute (RTI) in 2010 on a study ofe-referral systems in Zambia advocates for electronic patient referral systems asa precursor for full-scale electronic medical record systems (EMR). In comparisonto India, Zambia has a significantly higher MMR at 750 per 100,000 births. Theproject moved the referral and recording system of pregnant women from handwritten booklets to an integrated e-referral system. The project has yielded positive outcomes for both patients andphysicians. Physicians and staff now have immediate access to reportsconcerning patients’ referrals, care received, patient preparation, and patientdischarging to close the care loop.12 Diagram 1 (see Appendix) shows theschematic of how the system was set up. RTI concludes that in implementing areferral system in a resource poor setting, lack of human capital, lack of physicaland material resources, and low usage need to be considered to have asuccessful program.Other Viable Technology Applications for Referral Systems Many studies have highlighted telecommunications as an important toolin referring women with high-risk pregnancies to hospitals for treatment. Manysystems have been set up in such a way that community health workers makehome visits to pregnant women and use technology (radios, cell phones, PDAs)to refer and call ahead to facilities to ensure care for the women in danger ofpregnancy related complications.                                                                                                                12  Darcy,  N.,  Kelley,  C.,  Reynolds,  E.,  Cressman,  G.,  and  Killam,  P.  (2010).  An  Electronic  Patient  Referral  Application:  A  Case  Study  from  Zambia.  RTI  Press  publication  No.  RR-­‐0011-­‐1003.  Research  Triangle  Park,  NC:  RTI  International.  Retrieved  from:  http://www.rti.org/rtipress   | Health Information Systems to Improve Quality of Care in Resource Poor Settings | 8
  9. 9. E-Referral Systems for Maternal Health | Mumbai, India  The Cost-Effectiveness of Reducing Maternal Mortality in India A study published in 2010, estimated the cost savings of reducingmaternal mortality rates in India through specific interventions. These strategieswere based around improving coverage of effective interventions that could beprovided individually or packaged as integrated services, improved logisticssuch as reliable transport to an appropriate referral facility as well as recognitionof referral need and quality of care.13 The study concluded that reducingmaternal mortality is cost effective ($500 for package of interventions comparedto India’s GDP of $1,068) and that over 5-years the combination of the abovementioned services would save 150,000 women and over $1 billion.Implications of Findings Most of the literature points to sufficient referral systems as an essentialcompliment to strengthened health systems. The current pilot project in Mumbaiis an important first step in increasing and adequately using secondary andtertiary hospitals for antenatal care and obstetric emergencies. The three delays model should be take into consideration along with thecomputer based referral system. The pilot project deals mainly with the secondand third delays. It can be argued that the first level delays are most detrimentaland life threatening to mothers. Though the technology being used can’tmitigate the consequences of the first delay, it could be suggested that thepartner health clinics using the technology partner with community healthworkers to reach women before the situation becomes dire. The computer based pilot project referral system in Mumbai createsimportant linkages between levels of care. This sets up a safety net to providenecessary care for pregnant women in the forms of antenatal care, emergencycare for complications, and postnatal care. In order to ensure that the system                                                                                                                13  Goldie  SJ,  Sweet  S,  Carvalho  N,  Natchu  UCM,  Hu  D  (2010)  Alternative  Strategies  to  Reduce  Maternal  Mortality  in  India:    A  Cost-­‐Effectiveness  Analysis.   | Health Information Systems to Improve Quality of Care in Resource Poor Settings | 9
  10. 10. E-Referral Systems for Maternal Health | Mumbai, India  continues to add value to the physicians using it, its capabilities could beenhanced by providing hospital capacity, wait times, transportation options.Including theses measures will aid the e-referral system in reducing maternalmortality and morbidity.Problem Reformulation The absence of an effective referral system in Mumbai as a barrier toadequate emergency obstetric care was the initial view of the problem.Although this is certainly an element of the broader issue, addressing thisproblem alone will not solve the issue in the long term. Upon further researchand a more in depth examination of the literature, we found that the rising MMRin Mumbai is a multifaceted problem stemming from many sources. As previously mentioned the Three Delays Model is a more comprehensiveframework for examining MMR in Mumbai, and in general. Delays in seekingcare for an obstetric emergency; delays in reaching an appropriate obstetricfacility; and delays in actually receiving care once arriving at the facilityrepresent the three most common reasons a woman would suffer maternalmorbidity and mortality. Apart from the lack of availability and/or resources, high MMR in Mumbaican be attributed to non-utilization of services among expectant mothers. Poorhealth education and the resulting lack of awareness among expectantmothers regarding the importance of antenatal care and importance ofdelivery within a healthcare facility can affect the decision to seek care.Additionally, a woman’s decision-making power (or lack there of) within herhousehold has also contributed to low utilization of health services. | Health Information Systems to Improve Quality of Care in Resource Poor Settings | 10
  11. 11. E-Referral Systems for Maternal Health | Mumbai, India   Little awareness of healthcare facility location; poverty (inability to covercost of direct fees, transportation, drugs and supplies); and low service qualityare additional reasons women in India are reluctant to seek healthcare14. Improper referral systems represent another factor contributing to highMMR. A woman’s ability to reach the appropriate healthcare facility isnegatively affected when physicians are prone to inaccurate referrals. Mumbaiis currently experiencing underutilization of secondary healthcare centers andpatient overcrowding at tertiary centers as a result of little coordinationbetween primary, secondary and tertiary facilities. More specifically, primarycare doctors are referring patients directly to tertiary centers and thus notleveraging the availability of resources at secondary centers. Diagram 2 (seeAppendix) illustrates the considerations, phases and interventions in developinga referral system. By developing a patient tracking software, the pilot project in Mumbaiseeks to address this facet of the broader issue. This system would entail thatprimary care physicians complete a patient form and depending on theinformation provided the patient would be referred if necessary. If and wherethey are referred is recorded and a notification is sent to the referred carefacility where the patient uses an ID number upon admission to this facility.Inefficient and ineffective referrals occur mostly due to lack of confidence andexpertise among the health care professionals in Mumbai. Doctors are notconfident enough in their own knowledge and diagnostic abilities to referpatients to secondary centers and rather than risk making a mistake they referpatients to tertiary clinics for treatment. One reason for this could be the lack of connection between medicalprofessionals and the communities they serve. Medical schools are not                                                                                                                14  Kausar,  Rehana.    (2005)  India  Journal  for  the  Practising  Doctor.    Maternal  Mortality  in  India  –  Magnitude,  Causes  and  Concerns.    Vol.  2,  No.  2.  Retrieved  from:  http://www.indmedica.com/journals.php?journalid=3&issueid=58&articleid=722&action=article     | Health Information Systems to Improve Quality of Care in Resource Poor Settings | 11
  12. 12. E-Referral Systems for Maternal Health | Mumbai, India  preparing medical students to address the healthcare needs of the society.Although medical students in India are found to be adequate academicallythey often have insufficient clinical and problem solving skills. This is mostly theresult of how medical education is structured in India.15 Medical education curriculum in India typically places emphasis onabsorbing knowledge rather than the development of problem-solving;performance; attitudinal; or communication skills. Dr. Rita Sood, a doctor andprofessor at the All India Institute of Medical Sciences (AIIMS) feels thatgraduates should,   “…develop an ability to gather information with sensitivity and insight in order to make sound judgment on the basis of probabilities. Investigative medicine has largely taken over and it is not unusual to see inappropriate use of investigative procedures, some of which may increase the cost of medical care substantially and may even pose a risk to the patients. This is often associated with inadequacy to make a sound clinical judgment.”15     Issues with wait times and understaffing affect a woman’s ability toactually receive healthcare once at the facility. The aforementioned exampleof overcrowding at tertiary centers in Mumbai demonstrates how this mightcreate an obstacle to receiving healthcare. Tertiary facilities typically do nothave the capacity to serve the influx of all referred patients from primary centersand the resulting long wait times often deter patients from seeking care at all. In addition, we recognize that there is a cultural aspect contributing to theoverall problem. Organizational structure in Mumbai is very hierarchical andbecause doctors are perceived as a major authority within society there istypically no structure or person to oversee or direct these Doctors as a means tocorrect this problem. Socio-cultural challenges also exist. Resistance to a newway of referring patients, as well as resistance among the patients themselvescan present challenges with regard to the new system. Financial constraints alsointerfere with the pilot project being accepted.                                                                                                                15 All  India  Doctor  Associate  Blog:  Retrieved  from:    http://aimddadoctors.blogspot.com/2010/12/educating-­‐our-­‐doctors-­‐our-­‐doctors-­‐have.html     | Health Information Systems to Improve Quality of Care in Resource Poor Settings | 12
  13. 13. E-Referral Systems for Maternal Health | Mumbai, India  Recommendations Based on our findings we have gained a more comprehensiveperspective on the problem of rising MMR in Mumbai. Given the extensiveinformation on the multitude factors that contribute to this problem we see theneed for a multifaceted approach. While the patient tracking software beingused in the pilot project will address the delays regarding improper referral andissues with wait times, it fails to address the first delay noted in the Three DelaysModel – recognition of a health problem and the decision to seek care. Considering the high number of maternal deaths that occur due to lackof awareness and absence of health education we feel the project shouldconsider an education element as a way to increase awareness of theimportance of antenatal care. In preparation for scale up of the pilot project we recommend an analogsystem to share up-to-date information regarding capacity levels of allparticipating facilities. If the referring facility could be informed of the number ofavailable beds at the receiving facility referred patients could avoid long waittimes that in some cases could mean one more life lost to an obstetricemergency. As a way to mitigate issues with transportation we suggest developingpartnerships with the state or other NGOs to provide travel stipends for thosepatients without access to a vehicle. Also, a vehicle should be designated totravel between referral facilities for emergency situations. Finally, we recommend developing mechanisms to promote a culturaland attitudinal shift to mitigate management challenges; the mindset towardhierarchy within an organizational structure; and encourage communicationamong staff at healthcare facilities. | Health Information Systems to Improve Quality of Care in Resource Poor Settings | 13
  14. 14. E-Referral Systems for Maternal Health | Mumbai, India  Appendix Diagram 1 | Health Information Systems to Improve Quality of Care in Resource Poor Settings | 14
  15. 15. E-Referral Systems for Maternal Health | Mumbai, India   Diagram 2 | Health Information Systems to Improve Quality of Care in Resource Poor Settings | 15