Quality Care for All

One of the most fundamental questions for franchises is how to provide quality, standardized care. For some time, franchises and clinics have made use of standardized protocols to accomplish this goal. Unfortunately, paper-based protocols have proved to be so cumbersome that many doctors and health workers forgo them completely. But, with the growth of mobile health (mHealth), the use of mobile phones and other technologies to quickly and easily communicate these protocols has flourished. Marc Mitchell, a lecturer at the Harvard School of Public Health, has been leading the work in this realm with his organization D-tree International, which aims to change the way healthcare is delivered through the use of clinical decision support software (CDSS), i.e. electronic protocols. We had the opportunity to speak with him to get his insights on CDSS and its potential application to social franchises for health.

Trevor Lewis: How is CDSS being used in developing countries?
Marc Mitchell: In general, CDSS is being used to support health workers that are undertrained for the task that they are asked to do and so you are really trying to upgrade their ability to manage patients. Specifically, D-tree is doing a lot of work in Tanzania and Malawi to cover child health, maternal health, and some of the non-communicable and communicable diseases such as TB and HIV/AIDS. That is expanding because ultimately you want it to cover a wide range of diseases and health focuses rather than just one or two. We are also doing some work in India with the ASHAs (community health workers for reproductive health).

We are working with both clinics and hospitals and community health workers. The reason why were not specializing in one or the other is that we also are linking them. So for example, we’re linking antenatal care between the clinic and the community health worker. That becomes really important because many people come for one antenatal visit to a clinic never to return. It’s important that if there is a community health worker, they can follow up and talk to the mother and perhaps get her to come back to the clinic.

TL: What type of technology is CDSS being run on and why?
MM: There’s a lot of debate on what are the appropriate platforms for delivering this. We personally decided to use cell phones for a number of reasons. One is that in clinics you often do not have electricity all the time. Even in Dar-es-Salaam, there can be blackouts of up to 12 hours, and even a laptop won’t make it that long, whereas a cell phone might. Another reason is that you can use the connectivity of the cell phone to transmit data. Even if you have a computer AND electricity, you are not necessarily going to have functioning internet. Not to mention that phones do things that even computers don’t do: a phone knows where it is, using GIS; a computer doesn’t. Phones also have cameras that you can use for diagnostics and more.

But then there’s a third thing, and I think this is significantly underplayed. When you go see a doctor in the US, if they have a computer, they’re just sitting at the keyboard entering what you say and you don’t feel like they’re talking to you; they’re talking to the computer. But with a phone, you don’t have that feeling because a phone is small and it doesn’t stand between the patient and the doctor in the same way that a computer does.

TL: Do you think CDSS can be a useful tool for health franchises?
MM: I absolutely do. I think that there are at least two reasons why it particularly suits franchises or any type of private clinic looking to brand itself. One is that you are delivering consistency. In fact we are publishing a paper that shows that electronic IMCI is better; it gets better results, more correct diagnoses and much more consistency in delivering those good results than the standard paper-based protocols. So I think that one way that health franchises can use CDSS is to use it as part of their branding: “We deliver consistent, high-quality care and if you go to any of our facilities, you’re going to get the same care.” As an analogy, what makes McDonalds successful is that anywhere in the world, a Big Mac is the same. You can get other things on the menu, depending on where you go and what it is you want, but a Big Mac is the same and that’s what makes its brand.

The other benefit to health franchises is standardizing and controlling costs. It’s very easy to run up costs with laboratory test and polypharmacy (the prescription of a number of drugs) but one of the things that this type of decision support does is it says, “Ok, you need this laboratory test, not these sixteen laboratory tests and you need this drug, not these four drugs.” So it should be a way to manage costs with standardization.

TL: What are the other benefits of CDSS?
MM: I will use an anecdote here. We have been developing software for antenatal care that was in use at a clinic in Tanzania. One of our employees in Germany was monitoring the data from the CDSS and found that the fetal growth of a pregnant woman in the clinic was not adequate. An alert was automatically triggered on the clinic’s nurse’s phone that in turn triggered an electronic referral form. Nevertheless, the employee in Germany noticed that the nurse wasn’t filling out the form, so he sent a text message to remind the nurse and she said, “Oh, I forgot. Thank you very much!” And so that pregnant woman in fact got referred. You can imagine a situation where workers in a clinic are using phones equipped with CDSS, and somebody at a central point in the country is monitoring a sort of dashboard which shows alerts that are triggered. In this way, that person can make sure that problems are adequately addressed. It is exactly the remote monitoring that is one of those things that is so powerful, because real-time supervision is a very different thing from supervision that happens once a month or never happens.

TL: What are the biggest challenges that you’ve faced in implementing CDSS?
MM: The biggest challenge now is that people are looking for a panacea and mHealth or CDSS is not a panacea. There are things that mHealth can do, but if your system doesn’t work or you don’t have drugs in the clinic, then your system is broken and a phone isn’t going to cure it.

There is also often a lot of concern that health workers won’t like to use the phones, that they will feel like we’re taking their jobs, that the parents aren’t going to like it, or that the health worker will talk to their phone instead of to the patient. But we’ve carried out a study and the results are overwhelming that both the providers and the parents like the phones and the delivery of decision support, because they make the health workers more reliable. The mothers like it because they understand: this is better care.

Another issue is a cultural clash between health planners and people involved with technology. The rate of change in healthcare in developing countries is pretty slow, while the rate of change of technology, especially mobile technology, is warp speed, creating very different expectations about when and how changes happen. This can result in a number of problems. For example, a ministry of health might say “We want to standardize on a particular platform. We’ll all use Nokia phones and a particular Nokia phone.” And by the time they decide which phone to use, that phone isn’t being made anymore. You need to take advantage of the rate of change; you need to design things that are based on tomorrow’s technology, rather than on the technology that is here today.

TL: What infrastructure is it necessary to have in place to effectively implement this?
MM: I think that we need to be careful when we design not to assume that all sorts of additional infrastructure will be in place in the clinics because it probably won’t be. That being said, there are certain things you need, and it’s particularly true when you go to scale. For example, we, like many groups, are at a level where if things go wrong, we personally can fix them. If somebody’s phone stops working, we can replace it with a new working phone. As you get to national level, you can’t do that, so you need to create a system that can handle this function.

There are some other issues. Everyone is talking about how to charge the phones. That’s a big one because there isn’t electricity everywhere. Yet despite the lack of electricity, people everywhere somehow manage to get cell phones charged, so my response is: it is only when people like us get into the business of trying to deliver a system that charges the phones that we get into trouble. If we just leave it up to people to use whatever system is there, I think that we’ll be better off.

TL: When do you think that D-tree will have a final viable product?
MM: That is an interesting question. I would say that e-IMCI, is pretty much ready to go, but one of the issues is that I don’t want to deliver protocols that haven’t been adequately validated. When we start dictating how we’re going to be treating patients, I think we need to have real evidence that that treatment is effective and safe. In the end, all decision support should be held to the same standard as any new drug. That’s one of the things that slows us down, but one of the things that, in the long run, is going to be very important.

TL: Are there certain areas of health for which CDSS is particularly well-suited?
MM: Chronic care is an area that is particularly well suited due to the importance of longitudinal records and the importance of standards for non-specialists. You need to have non-specialists in diabetes be able to support patients who have diabetes in rural areas; the same with hypertension and other chronic diseases.

For acute illness, CDSS is most helpful for things that are common and easily diagnosed, such as malaria. The thing about childhood illness in low income countries is that a few diseases – mainly diarrheal disease, pneumonia, malaria – account for a huge amount of the mortality and morbidity. The same is true in neonatal care where, a few diseases, if treated correctly, could have a huge impact on child health, morbidity and mortality.

Our goal is to eventually deliver protocols for about 80 percent of patients that come to a health worker. Unfortunately, that last 20 percent is going to be very elusive, because then you start to get to things like heart disease in older patients or cancer diagnosis and treatment which get more complex and difficult to diagnosis. If we develop protocols for those things, it’s going to be a long ways off.

TL: What would your advice be to someone who is interested in implementing CDSS? MM: They should get involved and start doing it, but not expect that someone is going to come and deliver something next week. We had somebody who came to us because he wants to open up a set of clinics and anticipated that we could just deliver all of this to him in a month, and I said to him, “Thanks but no thanks.” So I think that somebody who wants to do it should get involved, but they should understand that there is a learning curve and they need to get far along this curve in order to understand how to use CDSS to their benefit.

TL: Any parting thoughts?
MM: CDSS is not just a passing fad and we’re only at the edge of the frontier. It is a very important and potentially very disruptive technology (in a positive way), and I think that if we are a little bit patient and willing to really see how this plays out, we’re going to see some amazing things happen in the next two to three years. I truly believe that it’s going to be worth the wait because, in the end, this is simply a better way to deliver healthcare.

This post is part of a series on social franchises for health leading up to the First Global Conference on Social Franchising (taking place Nov. 9-11 in Kenya). Find this post, and others in the series, here.