The document summarizes a project in India that used mobile health technology to support community health workers (ASHAs) in reducing maternal and newborn deaths. The project utilized a mobile app called CommCare that ASHAs could use to track pregnant women and newborns, provide counseling on health topics, identify danger signs, and ensure follow-up. The app included modules to guide the ASHA workflow for tasks like registration, management of pregnant and postpartum mothers, and young children. The project resulted in improved quality of ASHA counseling, increased home visit coverage, and targeted health behaviors like antenatal care utilization. Challenges included technology issues and high government leadership turnover. Lessons learned included the need for supportive supervision
Designing Health Systems For Group Encounters in Rural Rwandan CommunitiesTricia Okin
83% of Rwanda’s 12,000,000 population lives rurally outside of its main capital of Kigali. The Rwandan universal healthcare system was entirely built from the ground up after the Rwandan genocide as a way to address the health needs of all its citizens equally. This system, which is free to citizens, can successfully deliver quality healthcare at roughly $2 per person per year. It addresses the more immediate needs of the country’s rural citizens via an extensive network of healthcare centers and local community healthcare workers CHWs located in villages. Services offered at these clinics range from antenatal care, administering child nutrition programs, and diagnosing acute illnesses (including COVID-19 and malaria).
E-Heza is a tablet application used by CHWs in some of these health clinics. The ultimate goals of the CHWs are to diagnose, provide routine and simple care, and ultimately refer complex patients to the better equipped regional health centers. E-Heza’s primary role is to document patient care, support decision making, and lastly replace a paper-based system that required significant cognitive load on CHW and health center staff.
In this talk we’ll be addressing several topics:
How do we adapt the participatory design process when we’re unable to have direct access with the users of our designs? How do we build relationships with local healthcare team members when we have to design across geographical and cultural lines? How does the local team aid the work and send feedback back up the chain to affect design changes?
What does designing for a one-to-many healthcare interaction look like in terms of processing large segments of people and enabling non-clinical staff to make accurate medical decisions?
Are there parallel challenges to designing for American healthcare systems and those of rural Rwanda and how might they be affected by assumptions of class and race?
Designing Health Systems For Group Encounters in Rural Rwandan CommunitiesTricia Okin
83% of Rwanda’s 12,000,000 population lives rurally outside of its main capital of Kigali. The Rwandan universal healthcare system was entirely built from the ground up after the Rwandan genocide as a way to address the health needs of all its citizens equally. This system, which is free to citizens, can successfully deliver quality healthcare at roughly $2 per person per year. It addresses the more immediate needs of the country’s rural citizens via an extensive network of healthcare centers and local community healthcare workers CHWs located in villages. Services offered at these clinics range from antenatal care, administering child nutrition programs, and diagnosing acute illnesses (including COVID-19 and malaria).
E-Heza is a tablet application used by CHWs in some of these health clinics. The ultimate goals of the CHWs are to diagnose, provide routine and simple care, and ultimately refer complex patients to the better equipped regional health centers. E-Heza’s primary role is to document patient care, support decision making, and lastly replace a paper-based system that required significant cognitive load on CHW and health center staff.
In this talk we’ll be addressing several topics:
How do we adapt the participatory design process when we’re unable to have direct access with the users of our designs? How do we build relationships with local healthcare team members when we have to design across geographical and cultural lines? How does the local team aid the work and send feedback back up the chain to affect design changes?
What does designing for a one-to-many healthcare interaction look like in terms of processing large segments of people and enabling non-clinical staff to make accurate medical decisions?
Are there parallel challenges to designing for American healthcare systems and those of rural Rwanda and how might they be affected by assumptions of class and race?
Inca Clinic - Features and Benefits - Summer 2015Incaplex
Updated list of features and benefits of Inca Clinic - Summer 2015 Release. Includes an overview of Online Bookings, Appointment management, Vaccine Schedule, Patient Health Assessments. Hightlights benefits of Travel Clinics, Pharmacy, and Public Healthcare
* 77% of patients are willing to use virtual care
* Only 19% have tried it
* Patients won’t use it if they don’t know it’s an option
* Educating clinicians and patients to use virtual care
NHS e-Referral Service (ERS) presentation delivered by The Health and Social Care Information Centre (HSCIC) at the Healthcare Efficiency Through Technology (HETT) Expo - Oct 2013.
Launching or expanding a telehealth & remote patient monitoring (RPM) program can be an intimidating task
*HRS health system, home health & hospice
*HRS’ Client Success, Implementation,Reimbursement & Clinical teams
Developing a Web-based Integrated Dashboard for Health Information Systems, D...JSI
Presentation for the American Public Health Association & Expo, Atlanta, GA. November 2017:
Purpose: To examine the process and impact of developing an integrated, web-based dashboard for Health Information Systems Data: With the technical assistance from the USAID funded Health Systems Strengthening (HSS) program implemented by JSI Research & Training Institute, Inc., the Sindh Department of Health has developed an integrated on-line health information dashboard, linking all vertical program Management and Information Systems (MIS), and documenting all Lady Health Workers (LHW). Methods: In addition to supporting dashboard development, HSS has focused on improving the quality of data that is being generated through the routine health information system. The approach adopted by HSS includes direct support to staff working at on-line data entry points so that accurate and complete information is recorded. HSS also provides infrastructure support to district M&E cells. Results: The dashboard consolidates data from existing DHIS, MNCH-MIS and other vertical programs databases, all of which are supervised by the district M&E Cells. This integrated dashboard serves as the provincial dashboard and is fully interoperable with the DHIS and M&E systems in Sindh. As the project has matured, data quality continues to be improved. Discussion and Policy Recommendations: This online system resulted in desk-based, real-time data monitoring, through data dashboards and visual displays. Currently, online data of all public health facilities and in all districts across Sindh province is in place, and is being used for decision making. Health managers can review the performance of each and every health facility and provide feedback to improve the quality of data for achieving the desired targets.
Jackie Shears (Programme Head for NHS Pathways - HSCIC) presented the new NHS Pathways Intelligent Data Tool at the recent "Commissioning in Healthcare show (CiH 2015)".
Areas covered include:
· Background to NHS Pathways and the Intelligent Data Tool
· Guided tour of the new Commissioner Dashboard and what it can be used for
ENABLING AFFORDABLE HEALTH CARE SYSTEMS IN DEVELOPING COUNTRIES-CASE STUDYMehreen Shafique
Q1:
(a): What kinds of applications are described here?
(b): What Business Functions do they support:
(c): How do they improve operational efficiency and decision making?
Q2: Identify the problems that a business in this study solved by using mobile digital devices?
Q3: What kinds of Business are most likely to Benefit from equipping their employees with mobile digital devices such as I-Phones & Black Berry’s?
Q4: Devi Prasad Shetty’s CEO has stated “Now with 3-G, there are possibilities of remote treatment & diagnosis of patients through mobile phones. This will become mainstream in another two or three years.” DISCUSS the implications of this statement.
AppwoRx delivers mobile clinical photography, patient engagement, care collaboration and telemedicine solutions. RxPhoto is a robust mobile and cloud based clinical photography and collaboration solution. AppRx is a patient engagement and marketing tool.
Behind the front-end mobile functionality is a comprehensive online management system providing rich data aggregation and analytic capabilities.
Inca Clinic - Features and Benefits - Summer 2015Incaplex
Updated list of features and benefits of Inca Clinic - Summer 2015 Release. Includes an overview of Online Bookings, Appointment management, Vaccine Schedule, Patient Health Assessments. Hightlights benefits of Travel Clinics, Pharmacy, and Public Healthcare
* 77% of patients are willing to use virtual care
* Only 19% have tried it
* Patients won’t use it if they don’t know it’s an option
* Educating clinicians and patients to use virtual care
NHS e-Referral Service (ERS) presentation delivered by The Health and Social Care Information Centre (HSCIC) at the Healthcare Efficiency Through Technology (HETT) Expo - Oct 2013.
Launching or expanding a telehealth & remote patient monitoring (RPM) program can be an intimidating task
*HRS health system, home health & hospice
*HRS’ Client Success, Implementation,Reimbursement & Clinical teams
Developing a Web-based Integrated Dashboard for Health Information Systems, D...JSI
Presentation for the American Public Health Association & Expo, Atlanta, GA. November 2017:
Purpose: To examine the process and impact of developing an integrated, web-based dashboard for Health Information Systems Data: With the technical assistance from the USAID funded Health Systems Strengthening (HSS) program implemented by JSI Research & Training Institute, Inc., the Sindh Department of Health has developed an integrated on-line health information dashboard, linking all vertical program Management and Information Systems (MIS), and documenting all Lady Health Workers (LHW). Methods: In addition to supporting dashboard development, HSS has focused on improving the quality of data that is being generated through the routine health information system. The approach adopted by HSS includes direct support to staff working at on-line data entry points so that accurate and complete information is recorded. HSS also provides infrastructure support to district M&E cells. Results: The dashboard consolidates data from existing DHIS, MNCH-MIS and other vertical programs databases, all of which are supervised by the district M&E Cells. This integrated dashboard serves as the provincial dashboard and is fully interoperable with the DHIS and M&E systems in Sindh. As the project has matured, data quality continues to be improved. Discussion and Policy Recommendations: This online system resulted in desk-based, real-time data monitoring, through data dashboards and visual displays. Currently, online data of all public health facilities and in all districts across Sindh province is in place, and is being used for decision making. Health managers can review the performance of each and every health facility and provide feedback to improve the quality of data for achieving the desired targets.
Jackie Shears (Programme Head for NHS Pathways - HSCIC) presented the new NHS Pathways Intelligent Data Tool at the recent "Commissioning in Healthcare show (CiH 2015)".
Areas covered include:
· Background to NHS Pathways and the Intelligent Data Tool
· Guided tour of the new Commissioner Dashboard and what it can be used for
ENABLING AFFORDABLE HEALTH CARE SYSTEMS IN DEVELOPING COUNTRIES-CASE STUDYMehreen Shafique
Q1:
(a): What kinds of applications are described here?
(b): What Business Functions do they support:
(c): How do they improve operational efficiency and decision making?
Q2: Identify the problems that a business in this study solved by using mobile digital devices?
Q3: What kinds of Business are most likely to Benefit from equipping their employees with mobile digital devices such as I-Phones & Black Berry’s?
Q4: Devi Prasad Shetty’s CEO has stated “Now with 3-G, there are possibilities of remote treatment & diagnosis of patients through mobile phones. This will become mainstream in another two or three years.” DISCUSS the implications of this statement.
AppwoRx delivers mobile clinical photography, patient engagement, care collaboration and telemedicine solutions. RxPhoto is a robust mobile and cloud based clinical photography and collaboration solution. AppRx is a patient engagement and marketing tool.
Behind the front-end mobile functionality is a comprehensive online management system providing rich data aggregation and analytic capabilities.
Comparative Analysis of PAPR Reduction Techniques in OFDM Using Precoding Tec...IJSRD
In this modern era, Orthogonal Frequency Division Multiplexing (OFDM) has been proved to be an explicit promising technique for wired and wireless systems because of its several advantages like high spectral efficiency, robustness against frequency selective fading, relatively simple receiver implementation etc. Besides having a number of advantages OFDM suffers from few disadvantages like high Peak to Average Power Ratio (PAPR), Intercarrier Interference (ICI), Intersymbol Interference (ISI) etc. These detrimental effects, if not compensated properly and timely, can result in system performance degradation. This paper mainly concentrates on reduction of PAPR.A comparisons have been made between various precoding techniques against conventional OFDM.
ReMiND Pilot Project - overview of mobile application and content for ASHAsmhensley_CRS
Catholic Relief Services partners with technology innovator Dimagi, Inc. and Vatsalya to implement the Reducing Maternal and Newborn Deaths (ReMiND) Pilot Project in 2 blocks of Kaushambi district in Uttar Pradesh (India). ReMiND works with government community health workers (called ASHAs) to improve the frequency and quality of pregnancy, postpartum and infant home visits. ASHAs use basic mobile phones operating Dimagi's open-source CommCare software, which equips them with multi-media job aids to support client assessment, counseling, and early identification, treatment and/or rapid referral of pregnancy, postpartum and newborn complications. This presentation details the content and workflow of the CommCare-based mobile application developed for and used by ASHAs through the ReMiND Pilot Project.
Accessing Diabetes Education Through TelehealthTAOklahoma
M. Dianne Brown, MS, RDN, LD, CDE
OU Physicians Diabetes Life Clinic at the Harold Hamm Diabetes Center
Cynthia Scheideman-Miller, MHSA
Heartland Telehealth Resource Center
Oklahoma Telemedicine Conference 2014: Telehealth Transition
October 16, 2014
2. Project Duration: 4 Years (FY12 – FY15)
Partners: Vatsalya, Sarthi Development Foundation, Dimagi Inc. &
Government of Uttar Pradesh
Area of Intervention: 8 blocks of Kaushambi & 1 block on Lucknow
district
Beneficiaries: 13428 women & 12,308 children through 257 ASHAs
in two blocks
Total beneficiaries – around 1,42,000
Donors: CRS private fund, USAID small contribution DIV 2.0
Reducing Maternal & Newborn Deaths-ReMiND
4. ReMiND – What is it?
CommCare as a Job Aid for ASHA:
• Track and support woman through Pregnancy and
Postpartum periods
• Track and support baby from birth through first 2 years of life
• Localized and designed for ASHA use
Combines audio and still images for counseling and
assessment content based on ASHA Modules 2, 6 and 7
CommCare as a Decision Support tool:
• Helps the ASHA identify Danger Signs and make the
appropriate referral
CommCare as a supportive supervision tool
• Helps ASHA supervisors to manage ASHA performance
and provide constructive feedback.
4
6. REMIND APPLICATION SUMMARY:
Five Modules to Guide the ASHA Workflow:
1. Registration of Pregnant Mothers
2. Management of Pregnant Mothers
3. Management of Postpartum Mothers
4. Management of Newborns & Young Children
5. Referral Follow-Up
6
7. - Pregnancy Checklist
- Completion of ANC check-ups and Tetanus
Immunizations, Assess Use of Health Services,
Assess High Risks Signs in Pregnancy
- Pregnancy Counseling
- Information about High Risks and Pregnancy
Danger Signs, Antenatal Care, Nutrition, Rest and
IFA, Pregnancy Danger Signs, Birth Planning and
Preparedness, Essential Newborn Care
- Pregnancy Outcome
- Delivery information, Pregnancy outcome,
Newborn and mother’s health after delivery
- Modify Pregnant Woman Info
- Modify identification info for woman, and update
EDD/LMP information
PREGNANT MOTHERS:
7
8. - Mother Postpartum Visit
- Completion of Postpartum home visits,
Assessment of High Risks, Visit scheduling
- Postpartum Counseling
- Information about High Risks and Postpartum
Danger Signs
- High Risk Follow up
- Follow-up on high risks identified, Decision support
for assessing high risks
- Postpartum Review
- Review information about status and health of
postpartum mother, high risks identified, and next
scheduled home visit
- Close Postpartum
- To be filled 42 days post delivery once postpartum
phase is complete
POSTPARTUM MOTHERS:
8
9. - Home-based Newborn Care Visit
- Modify identification info for infant and mother, and
update DOB information
- Breastfeeding Assessment
- Additional follow-up for any mother/newborn with a
suspected feeding problem.
- Routine Immunization Tracking through 2 years
- BCG, OPV, DPT, Boosters, Polio, Measles, Vit A
- Routine Immunization Counsel
- Information about vaccines, benefits of
immunization, side effects, how/where to go
- Update Baby Info
- Update any details about the newborn case
- Close Baby
- To be filled to close the baby case after 2 years of
care and full immunization
YOUNG CHILD:
9
10. Supportive Supervision & Monitoring
Analysis &
use of
ASHAs’ real-
time data
Outcome:
Maternal, newborn & child
health outcomes
CommCare
HQ
Supportive
Supervision
Application
Quality:
IPC & counseling skills,
Mobile skills
Analysis &
use of real-
time
supervision
data
Active Data
Management
Reports
Output: Frequency &
timeliness of ASHA home
visits
SMS
reminders
& missed
visit alerts
10
13. Quality of counseling byASHAhas improved significantly
79%
100%
35%
77%
96%
94%
94%
100%
41%
50%
11%
24%
58%
59%
59%
85%
ASHA talked about her next home visit.
ASHA encouraged woman to use next
recommended health service.
Families who asked any questions.
Clients who asked any questions.
ASHA encouraged client to speak or ask
questions.
ASHA waited for client to respond before
moving to next audio message.
ASHA expanded on any of the CommCare
audio messages/questions.
ASHA greeted woman
Improvements in ASHA counseling tracked through facilitators’ observations
Sept-12 14-Sep
20. • Tailored handholding support to ASHAs
• Working with ASHAs who have no functional literacy
• Frequent change in the leadership in government at district
level
• Technology related issues
– GPRS problems
– Change in the settings in the hand set
• Engaging government in resolving tech issues
• Putting systems in place vis a vie leveraging technology
– Eg – ensuing ASHA visit & then making it ICT enabled
Challenges
21. • Make app more localized (such as voice of a local lady) and simple.
• With low-literate users, the mobile interface must ensure easy
navigation and training strategies must be adapted to maximize
learning.
• Immediate post training follow ups sustains interest and motivates
to practice.
• Need based supervision helpful in maximizing ASHA outputs.
• Strengthening local resources minimizes time in resolving
technology issues
• Understand the context well before launching the app
– Such as understanding capacities of ASHAs
Lessons Learned
22. • Success of a mobile app for ASHAs is dependent on having
sufficient supportive supervision for the ASHAs.
• Engagement of the government functionaries from the inception
enables easy uptake of intervention and increase their ownership
• Allow sufficient time at every stage – app development, training,
implementation and data analysis as well as its use
• Align with government programs and system
• Having tool is good. However, the purpose of using tool needs to
be given more importance than the tool itself.
Lessons Learned
23. Keep it simple
Test, Test, Test & Then Scale
Invest in building local capacities
It takes a team
Share & learn…learn & share
Summary and Close
Part of the rational for choosing to work in Kaushambi was that is was a GoI high-priority district & CRS was already working there. In an effort to increase access to health services the ReMiND program equipped ASHA with mobile job aids and monitoring tools.
In 2011, the district level authorities requested that ASHAs from Manjhanpur be selected for the initial piloting of the MNCH app. As the district seat, Manjhanpur allowed for closer participation and follow-up with district health authorities. When it was then finally time to go to scale in the first block, it made sense to stay in Manjhanpur because that is where the pilot had been and we already had 10 very experienced ASHAs to build from. The subsequent scale-up to Mooratganj was also strongly influenced by district health authorities’ preferences/recommendations. Network coverage and geographic access/proximity for Manjhanpur-based staff were also considerations in the decision to scale-up to Mooratganj.
ReMiND equips and trains ASHA on mobile-phone based tool to improve home visit counseling, assessment and referrals during the first 1,000 days of life (pregnancy, postpartum/newborn through first 2 years). ASHAs use basic feature phones (Nokia C2-01) operating Dimagi’s open-source CommCare software
Key Milestones- could also speak to when each app was designed and rolled out, and the various iterations.
March-October 2011: First version of MNCH app, showing enough promise for CRS to earmark funds. 10 pilot ASHAs
July 2012
Sector Facilitators are trained on ReMiND's monitoring and supportive supervision tools for scale-up of the pregnancy module to ASHAs
August 2012: Training 111 ASHAs (100%) in Manjhanpur block of Kaushambi on a CommCare-based pregnancy application.
March 2013:
USAID DIV 2.0 funding for an additional 149 ASHAs (100%) from Mooratganj
September 2013:
ASHAs are trained on the pregnancy referral and routine immunization modules of MNCH application
September 2014:
Roll-out of CommCare-based supportive supervision application to a new government cadre of ASHA supervisors across all 8 blocks of Kaushambi district and in partnership and in one block of the state capital of Lucknow.
Postpartum and baby modules of the MNCH ASHA application to be rolled-out in March 2015
Highlight the use of labels and color-coding (pregnancy = yellow, postpartum mother = green, baby = blue) to help low literate ASHAs more easily navigate the application.
Trained on Maternal & Newborn Child Health Care based on the GOI’s guidelines.
Hands-on training on using customized mobile application on java enabled phones.
On job support in conducting home visits and counseling of beneficiaries
Feedback from the blocks on performance application.
ReMiND is exploring ways to leverage mobile technology to strengthen ASHA supportive supervision and monitoring. This is currently done at 3 levels:
Output level monitoring and support focuses on tracking and improving the frequency and timeliness of ASHA home visits. This is done through weekly and monthly Active Data Management Reports. With the planned roll-out of the postpartum & infant applications, a system will be introduced that includes SMS reminders to ASHA to conduct home visits with missed visit alerts to ASHA supervisors if the visits are not conducted on time.
ReMiND is also using a CommCare-based mobile application for supportive supervision that includes tools for monitoring the quality of ASHA’s interpersonal communication and counseling skills during home visits, as well as their mobile use skills. This application is currently used by ReMiND Project staff, but is easily transferrable to ASHA Facilitators once that cadre is in place and to other ASHA supervisors. Real-time data generated from the use of the supportive supervision data can then be used to target support low performing ASHA and recognize those who are high performing.
At the highest level, ASHAs’ use of their CommCare-based job aids (mobile application) generates real-time health outcome data for every pregnant woman, newborn and infant they have registered. The project is currently doing quarterly analysis of health outcome data, but via CommCare HQ (Dimagi’s cloud-based server) the data can be accessed and analyzed at any time.
The supportive supervision and monitoring tool application that ReMiND is using allows supervisors to first register each ASHA in her area and then to individual follow-up and monitoring of each. The application contains the following forms/tools:
ASHA Follow up Form : Reports details of follow up visits with ASHA
Home Visit Observation Form : Tracks quality of ASHAs interpersonal communication and counseling skills with clients based on an observation checklist that the supervisor uses while accompanying ASHAs on home visits.
Mobile Experience survey: Assesses ASHAs’ skills at using the mobile application on her phone and other mobile use skills.
Technology Issue form : Gives picture of reported and resolved technological issues of ASHA’s phones
From the Technology Issue form is a Tech Issue Follow-up form that can be filled to report the status and resolution of the tech issues.
Meeting Form: Captures information about the type, time, place, participants and decisions made in different meetings attended (e.g., ASHA monthly meeting, ANM meetings, etc.)
All of the data the supervisors collect using this supportive supervision application is uploaded onto CommCare HQ where it can be regularly analyzed to track the quality of ASHA performance (home visit observation) and identify areas for strengthening.
This data is used in:
Discussion with ASHAs by HEO during meetings
Planning of SFs – to prioritize support to poor performing ASHAs)
Project Reporting
good to explain what we mean by high and low coverage when you speak to this slide also number of women who were never-visited by an ASHA from 39% to 24% of the sample population 39% to 24% would mean that 1881 fewer women did not receive a home visit (moving from 4890 to 3009 who did not get a home visit)
Counselling by ASHA, mobile phone is just to ensure the critical points are covered