E-Heza Data Solutions is a point-of-care digital application that improves workflows of health care providers and supports upstream data reporting. E-Heza aims to improve shelf-readiness by advancing its ability to provide standards-based interoperability with existing health records while building local capacity of technical teams in Rwanda and Burundi.
E-Heza Data Solutions is a digital health platform created by TIP Global Health (TIP) to improve health outcomes by prioritizing the needs of frontline health workers and the families they serve as the starting point for effective and resilient local and national primary health care systems. E-Heza is the first point-of-care digital tool designed to optimize high quality care for families across the entire ecosystem of primary health care from villages to health centers and hospitals with the ability to integrate with national systems that are critical for public health decision making. E-Heza inspires high quality data by utilizing data trends to provide personalized care, improve engagement in care, celebrate successes, and identify challenges before they become emergencies; all while preventing frontline health worker burnout by decreasing workloads, supporting workflows, and maximizing opportunities for meaningful interactions with their patients. So far, E-Heza has collected 15 million unique clinical data points through more than 200,000 care visits across four districts, serving a combined population of 650,000. E-Heza provides national protocol and decision support for most primary care services, based on World Health Organization (WHO) guidelines. This includes Covid-19 screening, referral, home-based care, and contact tracing functions, Integrated Management of Childhood Illnesses (IMCI) such as malaria and diarrhea, Community Health Worker (CHW) case management, Pediatric Care, Immunizations, Childhood Development, Family Planning, and Antenatal Care services.
E-Heza consists of a front-end user interface that communicates to a back-end database through an open source Restful Application Programming Interface (API). This provides the flexibility of integration with a wide variety of other database systems through the use of APIs. E-Heza open source software is licensed under the Apache License, Version 2.0. E-Heza conforms to most of the architectural principles set forth by the OpenHIE standards and supports workflows as described in the Electronic Medical Records Systems/Community Health Worker Solutions.
Through the Digital Square investment, TIP Global Health seeks to improve E-Heza’s shelf readiness in both the Rwandan and Burundian context. TIP is partnering with Village Health Works (VHW) to implement E-Heza among CHWs in villages and nurses in health facilities, and this investment will ensure that E-Heza is interoperable with their chosen hospital-based electronic medical record (EMR). TIP will work with the VHW team to select an EMR and ensure E-Heza’s primary care module supports standards-based interoperability and is built to OpenHIE standards. This would include both aggregate reporting to DHIS2, individual health records reporting to OpenMRS, and/or another system as appropriate for our consortium partners’ programmatic needs and their national government reporting expectations. In order to deeply understand stakeholder needs, TIP Global Health collects ongoing feedback from key partners and users for continuous quality improvement.
TIP Global Health is committed to ongoing development and capacity building in East Africa. To support local capacity in Rwanda, leadership staff from the Center of Excellence in Biomedical Engineering & E-Health (CEBE) will join our consortium. Their team will identify a student intern to support the implementation of the interoperability standards in both Rwanda and Burundi. By committing to local capacity building, we continue to ensure long-term sustainability of E-Heza’s impact on health outcomes as its implementation is further embedded into local communities.
TIP Global Health will lead and oversee the project and capacity building activities, working closely with CEBE and Village Health Works on interoperability requirements with support from Gizra on software development.
TIP Global Health actively participates in meetings with the World Health Organization and provides our expertise towards their Global Strategy for Digital Health. TIP Global Health contributed to the WHO Health Workforce department’s guidance on the topic of health workforce readiness for digital health. TIP Global Health also serves on the Technical Working Group for the Maternal, Child, Community Health (MCCH) Division at the Rwanda Biomedical Center and the Digital Health Technical Working Group at the Rwanda Ministry of Health. TIP Global Health, founded in Rwanda and the United States in 2008, is a leading authority in developing lasting solutions on the frontlines of health. TIP’s transformative approach to collaborating with frontline health workers, early alignment of its work with government priorities, and rigorous data-gathering, enables the scale-up of highly- effective solutions to extend access to life-saving quality care. TIP Global Health’s team includes experts in clinical care, digital health, project management, implementation, and monitoring and evaluation.
Key members of TIP Global Health’s team include:
Theophila Huriro Uwacu, MBA, Director of E-Heza Data Solutions. Theophila oversees all aspects of E-Heza’s development, implementation, and expansion. She has extensive experience in data collection and management and collaborates closely with frontline health workers and other stakeholders.
Dr. Valens Hafashimana, Director of Health Innovation & Acting Country Director. Dr. Hafashimana contributes to the organization’s overall strategy, overseeing the expansion of our innovations, and providing leadership and mentoring to our staff. He is an exceptionally experienced and compassionate physician with an excellent record of patient service and satisfaction, experience in capacity building for management of health facilities, and deep knowledge in maternal child health.
Adam Stewart, Chief Technology Officer, E-Heza Data Solutions. Adam has 20 years of experience working with NGOs and IGOs to implement digital solutions to confront real world challenges. Adam oversees the development process of E-Heza, and works in collaboration with the implementation team to deliver a new, best-in-class solution.
Dr. Wendy Leonard, Founder & Executive Director. Wendy Leonard, MD, AAHIVS is the Executive Director of TIP Global Health. Dr. Leonard has twenty years of clinical experience. She has extensive experience as an end-user of electronic medical record systems and serves on the OCHIN Infectious Disease Review Committee for EPIC use in OCHIN’s network of health facilities. Dr. Leonard supports the clinical aspects of E-Heza design, development, and implementation. She provides her expertise in health workforce readiness for digital health to the East Africa Health Research Commission and the World Health Organization.
Jeanette Pelizzon, UX Designer. Jeanette collaborates with the medical, implementation, and development teams to research Rwandan health protocols and translate them to a user-centric digital tool. She works closely with the development team to bring designs from ideation through QA testing to live deployment.
Diane Mahoro, Junior Software Engineer. Diane is a software engineer based in Rwanda and has more than 3 years of experience with PHP, Java, JavaScript, and Elm languages. She also serves as the frontline caretaker of technical issues that arise from work in the field. She is skilled in planning, analysis, design and implementation as well as maintenance of software.
Regional Centre of Excellence in Biomedical Engineering and eHealth (CEBE) is an institution of the University of Rwanda that provides the administrative leadership, intellectual capacity, and the resource infrastructure required to accelerate the delivery of cost-effective, technology-supported healthcare services in Rwanda and the surrounding region. The CEBE will support TIP Global Health in ensuring the interoperability layer aligns with both international protocols and local contexts. A CEBE faculty member will work alongside TIP Global Health’s software design and development team to build their capacity to provide training to their students.
Key members of CEBE’s team include:
David Tumusiime, PhD, Associate Professor, Deputy Director CEBE, College of Medicine and Health Sciences, University of Rwanda. David provides coordination of curriculum development, oversees postgraduate student supervision and mentorship, and is responsible for overall training, leadership, and mentorship at the Centre of Excellence in Biomedical Engineering and eHealth.
Village Health Works is a Burundi-based non-governmental organization focused on primary health care services integrated with education, sustainable agriculture, and economic development. Their team of experts in digital health and information technology will provide insight into the local context and benefit from capacity building through the implementation of this project. Village Health Works was founded in 2005.
Key members of Village Health Works’ team include:
Mack Kigada, Director of Information Services Group. Mack oversees the evaluation, selection, and integration of digital healthcare technology and information management systems for Village Health Works. He leads and coaches a team of data, IT, program, and community health professionals to maximize efficiency via the use of digital and technology-based systems and processes.
Gizra Internet Solutions will continue to support software development for E-Heza. Gizra, founded in 2009, is a fast-growing international software development company with an extensive track record in software solutions and implementation of content management systems. Gizra has a multi-talented team with dozens of years of experience. Their project portfolio includes: The UN Sustainable Development Group, UNICEF, United Nations Country Team Sites, United Nations Population Fund, and Harvard University’s OpenScholar among others.
Key members of Gizra Internet Solutions’ team include:
Anatoly Vaitsman, Web Developer and Team Lead. Anatoly is a full-stack web developer with a strong background of integration and delivery of complex systems. He is an experienced JavaScript developer and has senior level experience in Drupal theming, particularly in Drupal 8.
Amitai Burstein, CTO and Co-Owner. Amitai is the CTO and technology leader at Gizra. He is one of the top architects and contributors to Drupal 7 and Drupal 8 and a key architect behind the OpenScholar project. He also speaks regularly in DrupalCons and other open source events.
Aron Novak, Senior Developer. Aron is a full-stack senior developer with an emphasis on DevOps and has extensive experience with the UNICEF development team, having worked on a migration project and a long-term consulting and development project.
Background or Problem Statement
Existing digital health solutions are often inadequate to support the needs of rural health systems, where most primary health care is provided throughout Africa. Current digital health records were designed for simplicity of technology and national data reporting requirements, rather than ease of use, efficiency, or rural technological challenges. With current burnout rates among healthcare workers in some African countries already as high as sixty percent, digital tools must ease rather than compound workforce burnout and strengthen rather than stress clinician-patient relationships. With a global shortfall of 18 million frontline health workers and the pressure on the existing health workforce to provide more services to more people more often, it is critical that primary care delivery systems and associated digital health tools are designed to support their needs and their ability to provide higher quality care to the community members they serve.
Existing data reporting systems are robust, effectively storing and managing large volumes of data. This is essential because electronic medical records must access, organize, and store individual health records for millions of people over lifetimes. The Rwandan Ministry of Health utilizes a Health Management Information System (HMIS) built on a District Health Information Systems (DHIS) 2 platform to support aggregated public health data reporting to the national government. OpenMRS software serves as a national EMR to collect individual level health information at district and regional hospitals. Unfortunately, these systems have faced implementation challenges in local health jurisdictions – health centers, health posts, and villages – where most primary care services are provided. According to the World Health Organization, as much as 40% of a healthcare worker’s time in East Africa is spent on data entry rather than direct patient care. TIP Global Health set out to solve these challenges by creating E-Heza, with a focus on excellent user interfaces that integrate with existing national database systems and effectively support our health workforce’s ability to achieve the Sustainable Development Goals.
TIP Global Health co-designed E-Heza Data Solutions alongside frontline health workers and piloted the first project in nine health centers in Ruli District, Rwanda in 2019. Since the pilot program, TIP Global Health has implemented E-Heza Data Solutions across 321 villages in Rwanda and has served 75,000 patients through more than 200,000 visits on the E-Heza platform.
As digital health tools hold great potential to serve all of primary care needs across low- and middle-income countries, there is a critical need to build local capacity to support the adoption and implementation of such technologies. Developing the capacity of the current and existing health workforce is key to the adoption and integration of digital health technologies now and for the future.
Digital Health Technologies
In this project, we will adapt E-Heza development practices and software architecture to utilize the OpenHIE architecture as well as the Instant OpenHIE guidelines in order to decrease dependency on specific vendor tools and make investigation, adoption, and spin up easier for technical and non-technical users.
In terms of shelf readiness, E-Heza — as a point of service mobile system — sits on the “third shelf” in the logical overview of the OpenHIE architecture, and benefits greatly by situating itself to be leveraged efficiently by business domain services, such as HMIS systems which aggregate and share data, and shared health records, which allow multiple point of service systems to work with the same patient records. In our particular context, allowing accurately collected digital measurements to flow upstream to the country-wide HMIS (DHIS2) and shared with other point of service tools in hospitals (specifically, OpenMRS) is our desired end goal.
E-Heza has always used a containerized approach to development, using Docker images to support ease of installation and uniformity across platforms. More recently we have been working on Gitpod deployments, which non-developer users can use to spin up demos of E-Heza with the click of a button. This is an area of development to which our team is committed and we intend to learn from and contribute to the Instant OpenHIE initiative.
Instant OpenHIE affords our team the opportunity to abstract our approach to interoperability and to create a type of reference application that can be used to demonstrate interaction with an OpenHIM utilizing the OpenHIE architecture to support transaction of data. Past efforts have been made toward direct or indirect integrations to OpenMRS and DHIS2, which while beneficial, can be deeply enriched by a standardized and community-driven architectural approach. Our approach here would ensure that data shared between components would meet the FHIR standard and could ultimately be shaped into a FHIR-compatible resource.
Use Cases and User Stories
Work Package 1: Landscape analysis to assess interoperability needs of partners
- As the development organization director, I need to understand the needs of the local context so that I can determine the effort needed for configurations and customizations.
- As an implementing organization director, I need confidence in a software solution that will meet our clinical needs but will also be able to integrate into existing parts of HIE and be modeled for future scalability.
- As a government official, I need reliable, real-time data for decision making at the national and community level.
Work Package 2: Instant OpenHIE compliance
- As an implementing organization director, I need to automate business processes using OpenHIE so that I can scale my programs while ensuring interoperability across the existing HIE.
- As a developer for an implementing organization, I need to deploy E-Heza alongside other pieces of Instant OpenHIE with a preconfigured recipe for deployment.
Work Package 3: Stakeholder capacity building
- As an implementing organization director, I need CHWs to have a core competency in using the digital application so that we can minimize user support needs in the field where most users of the software will be in remote locations without access to further face-to-face training.
- As the developing organization director, I need a forum to hear feedback on key functionality so that these user feedbacks can be incorporated into the design/development process.
- As a CHW, I need to understand the workflows that are supported by the application so that I can maximize my efficiency in the context where data recording can create a burden on patient interaction.
Work Package 4: Alignment with Instant OpenHIE Initiative
- As a developer for an implementing organization, I need to deploy E-Heza alongside other pieces of Instant OpenHIE with a preconfigured recipe for deployment.
Work Package 5: Develop and deploy interoperability test cases to support key partnership workflows
- As a developer for an implementing organization, I want to be able to package my implementation environment into a deployable package so that deployments are efficient and scalable.
Work Package 6: Product documentation
- As an organization seeking integration and interoperability solutions, I need easily browseable documentation on E-Heza so that I can rely on my knowledgeable software team to configure and deploy these tools without relying on an external development team with specialized knowledge.
Objectives and Activities
The main objective of this project is to develop and implement an interoperability service layer to share workflows with DHIS2, OpenMRS, and another EMR as selected by TIP Global Health and Village Health Works. This improvement to E-Heza, based on the OpenHIE architectural approach, will support community and national policymakers’ decision making to add value to the end-user decision support already provided by E-Heza’s software, while building capacity of Village Health Works and CEBE. The E-Heza software is in the Operationalization and Maintenance stage of the software development life cycle.
Work package 1: Landscape analysis
Objective 1.1: Determine the interoperability needs for primary care in Burundi.
Activity 1.1.1: TIP Global Health will conduct a site visit to the Village Health Works team in Kigutu, Burundi.
Activity 1.1.2: Convene a meeting of key stakeholders to understand Burundi's existing digital health ecosystem, interoperability and data reporting needs, and future plans for scalability.
Activity 1.1.3: Survey CHWs and other relevant frontline health workers to determine their data reporting requirements.
Activity 1.1.4: Synthesize and analyze data collected in Activity 1.1.3.
Activity 1.1.5: Develop report of key findings based on Activities 1.1.1, 1.1.2, and 1.1.4, which includes the selection of the EMR with which to build an interoperability later.
Objective 1.2: Determine the needed configuration and customizations of E-Heza to meet the needs of frontline health workers in Burundi.
Activity 1.2.1: Assess E-Heza's primary care module in comparison to local context and needs.
Activity 1.2.2: Analyze feedback and develop plan for needed configuration and customizations.
Work package 2: Instant OpenHIE Compliance
Objective 2.1: Assess E-Heza’s alignment with Instant OpenHIE
Activity 2.1.1: Review OpenHIE Specification Overview and compliance requirements of Instant OpenHIE and document findings.
Activity 2.1.2: Review findings from Activity 2.1.1 and assess E-Heza’s alignment.
Objective 2.2: Align E-Heza with Instant OpenHIE
Activity 2.2.1: Implement software development changes necessary to align with Instant OpenHIE.
Work package 3: Stakeholder Capacity Building
Objective 3.1: Build partners’ capacity in interoperability
Activity 3.1.1: Work alongside consortium members and external stakeholders to meet Objective 1.1.
Activity 3.1.2: Partner with Village Health Works to support the deployment of E-Heza's interoperability layer in Burundi.
Activity 3.1.3: Partner with CEBE to support the deployment of E-Heza's interoperability layer in Rwanda.
Objective 3.2: Train partners in Instant OpenHIE to create OpenHIE ambassadors
Activity 3.2.1: Develop training curriculum for Instant OpenHIE
Activity 3.2.2: Conduct training in Rwanda for consortium members and key stakeholders on the Instant OpenHIE Initiative. A portion of the training will be focused on training trainers, so CEBE faculty can continue building knowledge of future developers and digital health leaders.
Activity 3.2.3: Conduct training for Burundian partners and key stakeholders on the Instant OpenHIE Initiative. A portion of the training will be focused on training trainers, so VHW staff can continue building knowledge of future developers and digital health leaders.
Work package 4: Alignment with Instant OpenHIE Initiative
Objective 4.1: Engage with the Instant OpenHIE Community
Activity 4.1.1: Participate in the OpenHIE Discourse and regular DevOps Subcommunity Calls.
Activity 4.1.2: Convene development team to identify areas to provide contribution.
Activity 4.1.3: Execute contribution plan.
Objective 4.2: Develop E-Heza to ensure that it can be deployed in an Instant OpenHIE implementation
Activity 4.2.1: Technical meeting to determine the technical requirements and resources.
Activity 4.2.2 Evaluate technologies for orchestration and deployment.
Activity 4.2.3 Develop the code which enables FHIR module and Instant OpenHIE compliance.
Activity 4.2.4 Publish the code which enables FHIR Module and Instant OpenHIE compliance including Dockerfile.
Work package 5: Develop and deploy interoperability test cases to support key partnership workflows
Objective 5.1: Automate interoperability test cases for the FHIR module and Instant OpenHIE
Activity 5.1.1: Develop automated interoperability layers for test cases.
Activity 5.1.2: Create and implement automated testing for interoperability layers.
Activity 5.1.3: Acceptance testing among stakeholders for interoperability test cases and remediation.
Activity 5.1.4: Document implementation plan for production cases of partnership workflows.
Work package 6: Documentation
Objective 6.1: Design and develop implementers guide
Activity 6.1.1: Draft documentation
Activity 6.1.2: Documentation acceptance testing
Activity 6.1.3: Incorporate feedback and publish
Objective 6.2: Design and develop clinical guide
Activity 6.2.1: Draft documentation
Activity 6.2.2: Documentation acceptance testing
Activity 6.2.3: Incorporate feedback and publish
Objective 6.3 Design and develop API Manual
Activity 6.3.1: Draft documentation
Activity 6.3.2: Documentation acceptance testing
Activity 6.3.3: Incorporate feedback and publish
Risk Mitigation
As we’ve encountered during the COVID-19 pandemic, there is a possible risk associated with traveling for site visits and convening stakeholders for in-person meetings. In lieu of meeting face-to-face, TIP has a contingency plan to conduct virtual site visits and online trainings as necessary. We have experience conducting other virtual training for NGO partners. There is also a risk that TIP is unable to find an intern in a timely manner. Due to our existing partnership with CEBE, this risk is low and CEBE faculty are committed to helping us recruit a student intern to support this project.
Community Feedback
E-Heza is an open source community project and is committed to the engagement with the broader digital health community as well as all project users and stakeholders. The project roadmap is driven by the E-Heza Executive Committee which meets bi-weekly and consists of members of TIP Global Health clinical and digital health teams, advisory members from the digital health community, and key NGO and governmental implementation partners. The committee will organize and solicit feedback for this project using three main methods:
- Our regular process of user feedback: TIP Global Health espouses an education model that includes listening, learning, integrating, and co-designing. Training with frontline healthcare workers seeks to understand functional and design needs as much as they look to provide key skills and knowledge. Our training module has built in feedback mechanisms that influence the design and development process.
- A landscape study with our organizational and governmental partners in Rwanda and Burundi. The study, proposed in Work Package 1, seeks to understand the healthcare ecosystems and to build for current interoperability needs and be predictive of future needs.
- Interaction with the wider digital health community, specifically the Instant OpenHIE project. The Instant OpenHIE initiative represents an extraordinary opportunity for E-Heza to build the interoperability tools today for the needs of tomorrow. We are eager to leverage this opportunity to be involved with the open source development community as a use case, to endure our own adherence to emerging standards, and to capture the aggregated knowledge of the community.
Schedule
The following schedule provides a high level overview of the activities, the team responsible for each, and their timeline for completion.
Deliverables
The following table provides details related to specific deliverables and their timeline for completion.
|
Deliverable |
Quarter Due |
|
Work Package 1, Objective 1, Activity 5 output, Report of key findings |
Q1 |
|
Work Package 1, Objective 2, Activity 2 output, Plan for E-Heza customizations and configurations |
Q1 |
|
Work Package 2, Objective 1, Activity 1 output, Assessment of E-Heza’s alignment with Instant OpenHIE |
Q1 |
|
Work Package 2, Objective 2, Activity 2 output, Software development changes to align with Instant OpenHIE standards |
Q2 |
|
Work Package 3, Objective 2, Activity 1 output, Training curriculum |
Q2 |
|
Work Package 3, Objective 2, Activities 2 & 3 output, Training feedback |
Q3 |
|
Work Package 4, Objective 1, Activity 2 output, Contribution plan for Instant OpenHIE Community |
Q3 |
|
Work Package 4, Objective 2, Activity 4 output, Publish code which enables FHIR Module and Instant OpenHIE compliance including Dockerfile |
Q4 |
|
Work Package 5, Objective 1, Activity1 output, Interoperability layers for test cases |
Q3 |
|
Work Package 5, Objective 1, Activity 4 output, Document implementation plan for production cases of partnership workflows |
Q4 |
|
Work Package 6, Objective 1, Activity 3 output, Publish implementers guide |
Q4 |
|
Work Package 6, Objective 1, Activity 3 output, Publish clinical guide |
Q4 |
|
Work Package 6, Objective 1, Activity 3 output, Publish API Manual |
Q4 |
Global Good Maturity Model Assessment
TIP Global Health’s E-Heza Data Solution shows a high level of maturity across the Global Goods Maturity Model. You can find the link to the assessment here.
Digital Health Atlas
https://www.digitalhealthatlas.org/en/-/projects/926/published
E-Heza Documentation
https://tip-global-health.github.io/eheza-documentation/
Comments
Digital Square comments
It is unclear what the license under the tool is and how well this aligns to the various aspects and definition of being a global good. Please ensure that this is updated in the full technical proposal.
Dear Carl,
Dear Carl,
Thank you very much for your feedback! E-Heza open source software is licensed under the Apache License, Version 2.0. We will be sure to clarify these details in the full technical proposal.