Tuesday, July 26, 2011


The month of May was an exciting one for the Mali Health Organizing Project because it offered the first chance to test out Medic Mobile's long-awaited PatientView program. PatientView is a lightweight medical records system that will enable clinics to use FrontlineSMS, the world's premiere open source text-message (SMS) platform, to coordinate community health worker (CHW) outreach, follow patient health status, support in-home care, and gather public health data -- all through a low-cost mobile phone.

PatientView relies on FrontlineSMS' Forms application to gather patient information from the field. FrontlineForms allows mobile phone users to receive form templates, fill them in and submit SMS messages containing the condensed responses to a central computer server, eliminating the need for users to remember codes in order to send complex information with a single SMS. When submitted, PatientView automatically matches these forms to a patient's file; these records can then be searched by patient identifiers, CHW, form type, or even specific responses. Thus, physicians can review patient histories and submit new patient forms on the computer. Physicians can also retrieve population data (i.e. number of malaria cases), and send text messages to community health workers to provide advice for in-home care or to make a clinic referral.

Together, these functions create a simple and effective medical records system for small health centers, while also adding the mobility necessary to support the CHW outreach that is often a critical part of expanding health care access in resource-poor communities.

The Mali Health Organizing Project (MHOP) coordinates one such CHW program, in partnership with two small community health centers in the Bamako slum of Sikoro-Sourakabougou. Serving over 20,000 people with microfinance, women’s education, sanitation, and health education programs, MHOP works to increase healthcare access through a multifaceted approach: encouraging care-seeking by removing financial barriers and increasing health knowledge, while developing low-cost interventions to improve the care provided by community health centers.  Action for Health, MHOP's flagship program, aims to reduce Mali's astounding 22% child mortality rate to less than 2% by focusing resources and diagnostic services on the five leading killers of children under five: malaria, acute respiratory infections, diarrhea, malnutrition, and measles.

To increase prevention and early care-seeking in these families, CHWs make bi-weekly visits to evaluate the health status of each child under five. They help families recognize warning signs and symptoms of the five major childhood illnesses and encourage them to use community health services early and often by providing health education, simple diagnostic services, and referrals to the local clinic for free treatment when the child shows symptoms of a covered illness. To maintain personal engagement, improve community health and make free care more sustainable, indigent families commit to completing volunteer health activities in return for these services.

At present, the CHW program relies on paper forms to record both home and clinic visits, which significantly complicates the patient referral and follow-up process. The CHWs record every visit and walk these papers to a weekly meeting, where they are reviewed and problems identified (i.e. children who should have been referred but were not, or who were referred but not followed up on correctly). Of these past visit records only the referral record is accessible to physicians when children are sent to the community clinic for care. In fact, physicians in the community clinics currently have no longitudinal medical information for any patient, because visits are recorded solely in a daily log; organized for the purpose of monthly case load reporting and accounting, this system makes it extraordinarily difficult to review an individual patient's care and treatment history.

Fortunately, with Medic Mobile's PatientView, all of that is about to change. Two weeks ago, MHOP's eleven community health workers were trained to use FrontlineForms on low-cost, locally available SonyEricsson phones. During a short afternoon meeting, the Malian program coordinator and I walked the team step by step through the process of finding, opening and manipulating the application. Then, we sat back as they tested it out, calling us over for questions as necessary.

At the end of the training, nearly all of the CHWs were able to send a form without assistance. We sent them all home with their phones for practice; a week later, each CHW confidently demonstrated their new skills by sending me a test form. Even Oumou Camara, who reads neither French or English (Bambara is the Malian lingua franca) proudly exclaimed that her son had helped her, and though he may have been a bit exasperated after a couple of hours, she now was able to send a visit form herself!

Similarly, the training and testing of the PatientView program with the clinic staff went off without a hitch. Eight physicians and nurses at the two community clinics involved in the CHW program convened for two three-hour sessions, working for the first time with the low-power computers purchased for the program. After a brief explanation of the system and a demonstration of FrontlineForms, we proceeded through a "typical" clinic consultation: searching for the patient's records, reviewing their personal information and medical history, and then filling out a consultation form. Six of the trainees said they had little to no prior experience with computers, but within the first two hours everyone was able to navigate the program unassisted. We spent the next afternoon discussing changes that could improve their workflow and help them provide better care and support to the CHW team. Thanks to the tireless work of lead developer Dieterich Lawson and the rest of the Medic Mobile team, many of these changes have already been made!

With the initial trainings finished, and final testing underway, we will officially launch the program with the beta release of PatientView in the coming weeks. Using free SMS credit provided by Orange Mali, CHW visit reports are sent directly to the local clinic. When a patient is referred, the physician records the clinic consultation, diagnosis and prescriptions, and follow-up information is sent to the CHW to help the patient complete their treatment and/or return to the clinic on a certain date. If the patient is not referred but has some symptoms (i.e., a day of diarrhea or mild malnutrition), these reports will be flagged for review. In response, the physician can send decision-support messages to the CHW (i.e., rehydration solution / fortified porridge / come to the clinic if not resolved in two days), using the patient's medical history tab to help determine the appropriate course of action. Because critical childhood vaccination schedules are not reliably recorded or accessible, vaccination reminders will also be sent for all children enrolled in the program.

Beyond improving services along the entire continuum of care, PatientView will make Action for Health more efficient and scalable. CHWs no longer have to spend four hours a week bringing these records to the program coordinator; instead they will be able to make visits to more than 300 additional children and the coordinator will have more time to focus on developing the education modules and volunteer community health activities that improve prevention of these common childhood illnesses.

To help bring this program to scale after pilot testing, the Malian Ministry of Health's Office of Telemedecine (ANTIM) will help develop a distributed Medic Mobile system. Making records accessible to second-tier referral clinics and hospitals through a national server, a distributed system will facilitate the coordination of other CHW programs across the country and help ensure that patients receive high quality services at every level of care.

Facilitating everything from in-home prevention, to clinic care and treatment support, PatientView will dramatically aid MHOP's fight against preventable child mortality -- and surely will do so wherever else it is used. We at Medic Mobile and the Mali Health Organizing Project are thrilled to bring this project to life after months of development, and we thank all of our supporters who have helped us along the way!