Everwell Health Solutions Pvt. Ltd. (“Everwell”) is excited to submit this concept note to Digital Square in support of Notice F0: Implementation of the World Health Organization Antenatal Care Digital Adaptation Kit.
We propose to enhance our platform, the Everwell Hub, 1) to support antenatal care management as per the WHO Antenatal Care Digital Adaption Kit and 2) enable sophisticated case management for pregnant women with pre-existing conditions/ comorbidities in a single platform. While the Hub is fully featured and in use in 15 countries across multiple diseases supporting nearly 2.6 Million registrations per year, the current structure is not adapted for antenatal care and supports one disease/ condition at a time. This proposal outlines enhancements that will enable us to create workflow based systems and empower users to track complex pregnancy journeys and also manage multiple medical treatments such as TB, HIV, diabetes for pregnant women within a single web and mobile user interface.
Everwell Health Solutions (“Everwell”) is pleased to apply to Notice F0: Reference implementation of the World Health Organization Antenatal Care Digital Adaption Kit to support the development and deployment of a shelf-ready case management system for antenatal care as per the WHO digital adaptation kit. Everwell has a vast experience in building and deploying large scale technical systems for public health and working across multiple health conditions globally to support healthcare delivery. We propose leveraging our shelf ready, open source platform, the Everwell Hub, to serve as a case management and integrated healthcare system to create a unified, consistent, and user friendly digital system for antenatal care programs. Everwell Hub has been deployed nationally in India for Tuberculosis (TB) management digitizing the entire cascade of care, integrating existing systems including diagnostics, adherence, and digital payments, supporting over 2.4 million new cases per year and used by over 400,000 healthcare staff. The Hub is also deployed in 14 other countries primarily for adherence support in TB and has also been adapted for HIV, mental health, COVID and oxygen management. We have worked with many health standards, including MDDS, HL7, HIPAA, GDPR, SNOMED, and have ISO 27001 certification for practices and policies maintaining technical systems for secure and private data. Everwell has over 6 years of experience developing and deploying large scale technical systems in public health and will drive the technical vision and implementation of the work. The following proposal provides a detailed specification of customizing the current platform and building an MVP of an interoperable digital health information system for antenatal care as per the WHO Digital Adaptation Kit.
The system would also be designed to enable integrated workflows for pre-existing conditions/ comorbidities for the pregnant women to enable holistic care. Our total budget is USD 150000 for 12 months of support, with a staged approach starting with scoping, technical definition and architecture, workflow customization, data standard adoption, and a pilot rollout. Given the timelines, Everwell has carefully defined ambitious, yet achievable targets for the proposal. The goal is to build a configurable platform for antenatal support and multi-episode treatment journeys with minimal need for customizations and create a shelf ready platform.
Everwell is leading the development of this concept note as a technical proposal for platform enhancement. We have active partnerships in several countries globally through which we would take partner feedback, suggestions, and ultimately demonstrate new features with. Some of our country deployments include India, Bangladesh, Myanmar, Vietnam, Philippines, Ukraine, Ethiopia, Uganda, Tanzania, Mozambique, Nigeria, DRC, South Africa where we do have local association and partnerships. As an open source toolkit, any developments to the core platform benefit all partners, and should this proposal go through we would select a few centers of excellence as demonstration sites for the new features.
At Everwell, our philosophy is that engineering, research and evaluation, and organizational capacity building in our users is the key to developing user-centric, reliable, scalable software systems to support healthcare practices globally. All of our work is open sourced; we release our code under the MIT license which is one of the most permissive licenses available. Both our approach to sustainability and our technical commitments to open source allow partners to customize and manage projects after Everwell’s initial involvement.
- Background or problem statement:
Innovations in the field of case management have been in the forefront of technology led solutions in public health for close to a decade now. In many LMICs, formal case management in the maternal health space is often paper based or non-existent even. Our objective is to disrupt this status quo by promoting healthcare staff to use a sophisticated yet simple platform to formalize the antenatal care journey. The Hub already includes features including patient registration, adherence, follow-up features to ensure medication compliance, capturing patient medical histories, drug dispensation, virtual care interventions. The Hub can be adapted and deployed as a case management platform to support antenatal care as per the WHO adaption kit and also be leveraged to deploy solutions such as case registration, adherence to IFA supplements and dispensation of medication to pregnant women. Health care workers (FLWs/ others) can monitor the entire pregnant woman’s journey via a single user interface on the web or mobile app and support her on the treatment journey. Enhanced engagement with PW can be implemented using personalized care tools.
With countries focusing on digitizing the cascade of care, the need of the hour is to also facilitate comprehensive case management that is not restricted or limited by disease or medical condition type. Currently, standalone case management systems exist that can be limiting to healthcare officials in terms of functionalities. Navigating through multiple complex systems in case of different medical conditions can be very overwhelming to already overburdened healthcare systems.
For instance, we have observed that in a lot of countries, HIV testing is mandatory for pregnant women at the start of the third trimester. In the unfortunate event that a PW is tested positive for HIV during pregnancy, a new case, in yet another standalone system will have to be opened for relevant follow-up and service delivery. Our proposed solution addresses these very kinds of challenges with an attempt to support multiple episodes in any pregnant woman's journey.
- Objectives of the proposed Solution:
Through this solution, we aim to deploy an instance of the Hub for better case management in the maternal health context. Additionally, in an attempt to make our existing case management platform more comprehensive and intelligent, we propose to design and deploy a revised episode service module. Objectives of this module are:
- The primary objective is to support the case management for antenatal care encompassing the entire treatment journey for a pregnant woman. These adaptations will be done in accordance with the WHO Antenatal Care Digital Adaptation Kit. This will encompass both functional (e.g., follow-up schedules for every trimester) and nonfunctional requirements mentioned.
- Additionally, we will enhance the platform to allow seamless record management of pregnant women who could have complex pregnancy journeys due to multiple medical conditions impacting their pregnancy. These conditions could be varied in nature -- non communicable such as hypertension, hyperglycemia, cancers, or other respiratory ailments; they could also be individuals with infectious diseases such as HIV, TB, HepC or others. Our Episode Module aims at addressing these issues by creating a unique case for the pregnant mother with multiple “sub cases” or “episodes” that will allow for individual conditions to be addressed within the same system.
- The proposal will also bring all the existing modules (microservices) deployed as part of the Hub to this Episode Module for antenatal care such that additional engagement mechanisms (such as SMS, IVR, adherence monitoring, drug dispensation monitoring) can be leveraged. This will include enabling modules and the ability to customize workflows such as adherence, engagements (SMSs, IVRs), dispensation, diagnostics, social security pay-outs, etc. within the episode management module.
The long-term objective of this solution is to ensure that this solution can be adapted and used for antenatal care and can be interoperable to exchange data for a particular “episode” with any other existing digital health systems in the country, if required.
- Deliverables & Schedule:
|
Activities |
Description |
Planned Timeline (Months) |
Planned Deliverables |
Estimated Budget (in $) |
|
Antenatal Care Adaptation |
This module shall be enhanced and allow deployment owners (i.e., Government stakeholders, researchers or NGO project leaders) to adapt for antenatal care and develop multiple treatment journeys or workflows to support other conditions parallelly. |
5 |
Module webpage, & screen in the app as per the requirements |
70,000 |
|
Beneficiary interface to their health portfolio |
Our platform will also include a beneficiary centric (i.e., citizen, patient) application so they can access their health details, information, resulting to encouragement and better engagement |
2 |
Companion application (Android) available for beneficiaries in select geographies |
35,000 |
|
Compliance with OpenHIE standards |
Ensuring the Hub's compliance with global standards. |
2 |
Completion of compliance with standards |
25,000 |
|
Creation of training materials (static and interactive) in multiple languages |
Designing training material for users of the new modules, including interactive tutorials/ guides. |
0.5 |
Completion of training materials (available in public domain) |
10,000 |
|
Implementation demonstration with at least one partner |
Deployment of the new modules with at least one of our existing modules for rapid feedback and testing, and to seed uptake. |
1 |
Live deployment in at least one environment |
10,000 |
|
Total Estimated budget |
$ 150,000 |
|||
We estimate that we can complete the overall objectives in 9 months, subject to the final requirements for each module. Some activities can happen in parallel, but the core engineering developments would happen sequentially.
We create training and scaffolding tools to enhance local capacity. We will use a combination of audiovisual materials explaining each module, alongside interactive tutorials in the web and app to walk new users through workflows.
- Risk Mitigation:
The Everwell Quality Assurance (QA) team ensures that all features shipped have gone through rigorous manual and automated testing. Our team follows technical releases on fixed days, whereby any newly developed code is first deployed on a beta server to allow for robust testing and quality assurance. We have a suite of automated tests that cover basic workflows and ensure scalability and uptime of releases, as well as manual workflow testing. Code releases are only pushed into production environments when all QA processes and testing are passed.
Everwell is an ISO 27001 Certified organization and maintains the good practice framework as per ISO 27001 protocols for establishing, implementing, operating, monitoring, reviewing, maintaining and improving an information security and management system (ISMS). We implement best practices in data security and privacy, and take extreme precautions to protect data captured on the platform. We also rely heavily on our partner network for guidance and feedback on feature development, and would take their feedback for any proposed design.
Comments
Digital Square comments
Thank you for the application. For the full technical application, in addition to general recommendations per the email, please expand more on:
-How standards work will be integrated throughout the project, what specific compliance activities are planned, and which standards.
-Specifics on which DAK components/which parts of the ANC FHIR implementation guide will be used.
Since applying logic when there are multiple conditions to be considered is particularly complex and is an area actively being worked on in the global health community--and as it's a primary objective for this work--would like to understand if the team is already familiar with this area and what might be reasonably achievable in the project timeline, associated standards here, potential dependencies, etc.
A beneficiary interface and associated requirements that would be needed for it are outside the scope of the ANC DAK and its targeted, primary users.
Also see out of scope list related to implementation activities.
Thank you for a great
Thank you for a great application. Please elaborate on:
1. Is the product open source
1. Is the product open source and what is the community governance mechanism.
Yes, the Everwell Hub has always been open source. Any and all deliverables are developed for the global good, and will be open sourced to benefit any partner wishing to leverage our work. These open source deliverables do not include any data or otherwise confidential information captured by the platform—such information is stored in secure and encrypted servers. Following is a brief description of our key open source verticals:
Our governance structure is currently ISO 27001 (or more formally, ISO/IEC 27001:2013, Information Security Management Systems) compliant. This standard was developed by an international community of security experts. ISO 27001 lays out a good practice framework for establishing, implementing, operating, monitoring, reviewing, maintaining and improving an ISMS. The key purpose of the ISMS is to bring information risk and security under management control, using a management system similar in structure to those used for quality (ISO 9001), environment (ISO 14001) and others. The ISMS will provide us with a systematic approach to combating a broad range of security risks to both our own proprietary information assets and those (such as customer data and personal information about employees) over which we have a duty of care. In addition, a formal certificate of compliance with ISO 27001 will enable us to demonstrate to customers, business partners and other stakeholders that we take utmost care towards our information security responsibilities so that the data stored or trusted with us are maintained with maximum security and constant vigilance.
2. How will the applications be expected to align and strengthen the shelf-readiness.
Bearing the broader definition of shelf readiness in mind, where in the system will have all the necessary tools and functionalities ready for immediate deployment, the Hub is designed to function exactly in that sense. With its advanced and quick deployment the Hub works in an almost plug and play fashion, where partners (implementing or investors) could pick from a wide range of microservices needed for a rapid deployment. It is also this very feature that has enabled the Hub to be rapidly deployed in over 14 countries and across 4 public health crises including TB, HIV, mental Health and LTBI. This grant will be directed towards making the existing platform more robust in the maternal health space thereby allowing partners who would like to deploy the same to simply add in their OTT customizations as necessary.
3. How will the application be expected to incorporate key data standards and align to workflows.
Existing health information architecture projects such as openHIE have defined a number of patient based workflows using FHIR, this project will focus on building artifacts and APIs for case management details for ANC. We envisage an incremental process whereby an initial set of base FHIR resources are the immediate focus - such as case registration, deduplication, the like. This will enhance the interoperability and shelf readiness of the Everwell Hub where required. We envision the following broad steps that will help us incorporate data standardization and alignment with workflows:
More details of our work plan as a part of this work package is defined in Work package 3 of our application.
4. How will you ensure that the applications can fulfill the data exchange needs of the DAKs.
The Everwell Hub is a platform which has a flexible data model and an API which lends itself to interoperability and building layered functionality on top of it. We will use the FHIR infrastructure (particularly the datatypes and the terminology services) to create structured, coded representations of the information we want to exchange--these will be in line with those defined in the DAK. Our platform also allows integration with the other digital systems and tools that are accessed through APIs. We could conduct a one-time data transfer from the different sources identified to Everwell Hub. Post this, while healthcare workers could continue using the existing digital systems that they use, using the Everwell Hub as a platform for direct data entry would allow for standardized protocols and data capture methods in the long run. Data from the source systems would be mapped to the Everwell Hub post reconciliation allowing for a seamless flow of data between systems. We will use the DAK as the source of truth at the time of defining these components and they will be built on FHIR infrastructure making data exchange between systems as seamless as possible.
5. How will you ensure alignment with OpenHIE approach and interact with other solutions.
With dedication to users and excellence in our product as core values, we at Everwell have been striving to build and deliver user centric solutions and products. While for many innovations, one can design for themselves because they are a peer to the user, in global public health, sometimes one’s intuition can be misleading as the users are often very different from the designer or developer. To balance and inform decisions therefore, we at Everwell rely on spending extensive time talking with users and the design community consisting of peers and thought partners about designs or protocols. This is where we also intend to leverage the vast knowledge and expertise of the OpenHIE community (detailed in the Community Feedback section of the application). Additionally, Everwell will leverage its partnerships and network and share country implementation activities while also sharing learnings within the OpenHIE community. Everwell is committed to provide available time and resources to assist OpenHIE leadership in prioritizing activities within the larger OpenHIE community roadmap. We are continuously exploring new ways of collaborating across other teams and work streams at Everwell, including platform design, app development, and implementation research.
Addressing the interaction with other solutions, in most countries we find the existence of many different and isolated health information systems, causing numerous information management challenges. In such contexts, integrating existing health information systems and designing technology solutions that can be interoperable becomes pivotal. In a first step, focusing on reducing the number of parallel systems and identifying the most relevant systems, following which integration of the identified relevant systems is a befitting starting point. As a part of this project, identification of relevant systems for integrations will be the initial plan to ensure that the Everwell Hub is not just another standalone solution, but is one that can communicate and interact with other solutions in an effective and efficient manner. Following this, as mentioned in the previous section too, we will use the DAK as the source of truth at the time of defining necessary components and they will be built on FHIR infrastructure making data exchange between systems as seamless as possible.