Notice C

Promoting the collaborative development of proposals for investments in digital health global goods

Scaling up Evidence-based Digital Patient-Centered Care: WelTel’s East African Hub

Primary Author: Richard T. Lester
Notice C Opportunity: 
Announcement C0: Global Good Software Development and Support
Application Status: 
Approved - partially funded

Global Good Requirements: 1) Existing software in >3 LMIC - Kenya, Rwanda, Uganda, Ethiopia. 2) Freely accessible adherence to the Open Definition for access to data - responsible licensing and support via social enterprise, non-profit, and global access principles. 3) Software applied in the Health Domain - primary health focus.

Consortium Team

Leading this project is WelTel, a social enterprise with a registered office in Kenya. WelTel thrives within this dichotomy, exhibiting success in the development, customization, deployment, and evaluation of digital outpatient management software in African countries.

 The non-profit began operation in 2011 in Nairobi, following the success of the first WelTel study (2005 - 2009), with findings that linked care delivery via text message with medication adherence, resulting in a decrease in viral load for patients with HIV. Operations have since expanded within Kenya (Northern Kenya, 2013) to clinics in other countries: Uganda (2012), South Africa (2016), Ethiopia (2016), and Rwanda (2018). The WelTel Kenya team includes a senior computer programmer, IT support, and field officers who support programs in Kenya, Rwanda, Ethiopia, South Africa and are starting up in Uganda. Currently, WelTel only has a small office of its own in Kenya to represent the African service region and relies on partner organizations for shared overhead.

For this application WelTel will partner with a number of relevant implementing partners who will share the resourced of the East African Hub and 2Paths will lead the data integration component.

2Paths (https://www.2paths.com/) to enhance data analytics for integration into open electronic medical records (e.g. OpenMRS) and health management information systems (HMIS, e.g. DHIS2). 2Paths has over 15-years experience in this field automating data flows, implementing open source health information systems and building tools to visualize and analyze complex datasets. 2Paths has executed on official contracts with PEPFAR, WHO and the Bill & Melinda Gates Foundation among other local and international clients, such as government departments and ministries, universities, international NGOs and other aid organizations and have also been subcontracted to round out technical expertise for specific projects. Project sizes have ranged from $25,000 to $1,500,000 and include:

-         Built data dashboards for PEPFAR to help showcase its track record of impressive outcomes to change the trajectory of the global HIV/AIDS pandemic. (2014-17)

-         Developed an application for the Institute for International Programs - Johns Hopkins University to address existing challenges with program evaluation of large-scale MNCH and nutrition programs in Mali, Malawi, Mozambique and Tanzania. (2015-17)

-         Built an application that automates the flow of project-level data into DHIS 2  for the International Rescue Committee. (2016)

-         Grameen Foundation and Bill & Melinda Gates Foundation sponsored project to develop a highly scalable open source mobile platform (MoTeCH) available to community health organizations serving remote and vulnerable populations who wish to implement a national scale mobile health system. (2011)

-         Consulted directly to the Bill & Melinda Gates Foundation on the technical architecture of the IATI standard in its nascent days. (2010)

-         Contracted by the Bill & Melinda Gates Foundation to work with the Organization for Economic Cooperation and Development (OECD) to deliver an application that provides users with one-button access to rich data about aid-flows between the reporting countries. (2008)

-         Developed for WHO a functional prototype of a health information mapping platform which helped to inform the direction of DHIS 2. (2007)

Amref Enterprise (Kenya), the Rwanda Biomedical Centre (Rwanda), the University of Gondar and eHealth Labs (Ethiopia), academic and implementing partners to assist in developing pathways and policies for scale, including integration into the public and private health sectors in the East African region.

 www.weltel.org

www.2paths.com

https://ehealthlab.org/

https://amref.org/

http://www.rbc.gov.rw/index.php?id=188

Project Description

 WelTel is a frontline digital health service designed to connect outpatients with their care providers in regular, reliable, low-cost ways using their mobile phones. It was founded, developed, and researched in East Africa since 2005. It’s a mobile health (mHealth) solution linking patients and providers, utilizing text messaging via short-message service (SMS), with voice calling (and now video where appropriate) support, to communicate health related issues from the patient’s perspective. It provides regular check-ins with outpatients and offers real-time, needs-based sorting of responses, and is a secure housing for patient-level data. Moreover, WelTel helps care providers better understand and respond to the needs of their patients while in the community. This interactive outpatient care approach distinguishes WelTel from simple texting platforms since its unique approach enables enhanced holistic care of patients, rather than a simple messaging service add on.

Since its inception, the development and refinement of WelTel has followed the directives of enhancing access, building equity, and saving lives. It offers greater applicability across disease-categories, populations, and geographies by utilizing more ubiquitous infrastructure (mobile penetration, accessibility of mobile units, & low-cost SMS) to enable clinics to “reach the unreachable”; it was one of the first mHealth initiatives proven to improve patient health outcomes in clinical trials (increased adherence to antiretroviral therapy (ART), higher quality of life scores, increased antenatal clinic attendance (ANC), and greater number of skilled birth attended deliveries in northern Kenya).The evidence generated from WelTel’s proof-of-concept studies has informed many other programs and international guidelines. Importantly, the WelTel technical service internalizes the learnings from the extensive research by its partners and others into its own product features, ensuring it leads with evidence-based best practices. Much of the research conducted on WelTel and its services has been published in top tier and open access journals. Program level health system data captured by the WelTel system belongs to the health service providers and authorities responsible to their populations, with appropriate data sharing agreements for research and quality improvement initiatives.  The global relevance of WelTel has amplified, as a viable solution for low-resource health delivery systems that also offers an ability to integrate with emerging health system technologies (i.e. EMRs, HIMS) as they are increasingly available in lower and middle income countries (LMIC).

With a focus on reciprocal learning and continual software refinement across continents, WelTel maintains versatility to meet unique health system needs. WelTel’s application in managing infectious disease in developing countries (e.g. HIV, TB) is paralleled with its emerging use in chronic disease self-management (e.g. asthma, diabetes mellitus). Within East Africa, countries like Ethiopia and Kenya are dominant leaders in mHealth integration into their health service delivery. While the willingness to adopt mHealth solutions as complementary strategies for health service delivery is high, the scale-up and wider adoption, especially in countries with less experience and fewer resources, has been low. Necessary next steps for mHealth in East Africa includes knowledge exchange, coordination, and strategic regional collaboration within and across countries to improve scalability (Lee, Cho, & Kim, 2017).

Challenges

Originating in Kenya, WelTel has a growing global presence with demand for projects now expanding in Canada, the USA, Belgium, and South Africa which is facilitating the core technology feature development and base for a sustainable business model. However, as WelTel continues to grow in East Africa, with new projects launched in Rwanda, Ethiopia and Uganda, there are multiple challenges we face that hinder our ability for sustainably and timely growth, including:

  • The lack of strategic regional collaboration. Many of the mHealth services offered in this region are still in pilot phase and struggle with scale-up over the long-term (known informally as pilotitis) (Huang, Blaschke, & Lucas, 2017). Although WelTel preceded the influx of pilots, WelTel’s expansion has also faced small level deployments. However, WelTel is considerably well-positioned for expansion, given its continued use, institutional knowledge from a history of iteratively overcoming challenges, and cross-cutting competitive advantages to alternate approaches that remain today - (see Community Feedback for developments around WelTel’s sustainability). Unfortunately, many organizations repeat facing the same challenges and may waste valuable time relearning lessons already learned by others. Only with strong intraorganizational and interorganizational collaboration, including exchange of best practices and knowledge between existing mHealth services in East Africa, will there be an efficient environment for scaling.
  • The lack of integration with other health system infrastructure, including electronic medical records(EMR) or HMIS. Many facilities currently using WelTel to assist in care delivery in East Africa still rely on paper charting, while others have an EMR where patient data is input either real-time or from charts after clinical visits. Since WelTel is primarily used for improving the front-line patient care experience and improving health indicators (ANC visit attendance, facility births, immunization uptake, reduced HIV/TB defaulter rates etc) and can be used as a standalone digital service, it can be used in adjunct with both paper and EMR charting, and the key indicators are captured by the existing systems. However, the WelTel platform also offers an opportunity to strengthen data capture quality, and capture data that is missed or unavailable by traditional medical records that exist only at the health facility level. For example, if a pregnant woman has a complication and dies in the community without reaching hospital, this information may not be captured in the facility level EMR, leading to under-reporting. In addition, because many individual patients access several different health service providers for various aspects of their care, due to mobility or differential value seeking, patients registered in WelTel remain their with their unique identifiers and contacts which can be used to harmonize different facility level data sources. For those facilities that have adopted EMRs, ensuring quick integration could offer time and cost savings in data exchange at the facility and national levels. Because WelTel is easy to adopt, it can also act as a bridge to more comprehensive EMR and HMIS adoption, sensitizing remote communities and facilities to digital services.

 

Despite its extensive evidence-base and development of a viable digital health outreach platform service, implementation at scale remains too slow to ensure global best practices are attained. Our own research determined the extensive potential for current implementation of SMS-based mHealth programs for MNCH in remote communities (REF) which directly aligned with a government sponsored assessment of the digital health landscape in Kenya. In a recent USAID program officer visit to northern Kenya’s Afyaplus program, the officer called it a ‘game changer’ since no other digital health technologies were able to work in the area. For this application, theDigital Square financial resources and partnerships will be used to strengthenWelTel’s ability to enhance, expand, and sustain mHealth services in East Africa in alignment with health system and population health priorities.

Core Activities

We will enhance the regional scale up of WelTel through activities that foster sustainability by breaking down silos (knowledge exchange, collaboration), that capitalize on existing infrastructure (enhancements to software), lobby for investments by the telecommunication sector, government, and non-governmental organizations (collaboration, global relevance), and integrate health system technologies (interoperability, open sharing). In summary, activities will contribute to Building Regional Collaboration & Exchange and/or Technology & Integration Enhancements within a 2-year timeframe (2019 - 2021).

A. Regional Collaboration & Exchange

  1. Creation of a Physical Hub/Headquarters (HQ):A regional headquarters will be developed in Kenya to serve as the administrative host for regional implementation. Core staff will be hired as well as a Regional Coordinator to liaise with country level programs and programs outside of Africa.

Core Activities (30%):

  • Expand WelTel Kenya Office (HQ Nanyuki which is strategically located with access to Nairobi’s tech hub and the remote northern communities currently using the service)
  • Hire East African Regional Coordinator & Administrator (admin assistance)
  • Expand office infrastructure (e.g. hardware)
  • Country site visits by Regional Coordinator (Y1: Kenya to Ethiopia, Rwanda | Y2: Kenya to Uganda, South Africa plus any new implementing countries)
  • Executive team visits (International, e.g. WelTel, 2Paths) for needs assessments, strategy, and administrative support.

Key Outputs:

  • In 2020, improved to administrative capacity and opportunities for collaboration for WelTel's sites with physical office space, hardware, and Regional Coordinator
  • Generated interest in WelTel for expansion within countries and beyond, including adoption or preludes to the adoption of eHealth strategies in these countries
  • Increase accountability and transparency to staff, stakeholders (e.g. health delivery systems) via visitations and timely reporting
  • Furthering investments internationally with recognition and physical point of contact - at least one new funder recruited
  1. Creation of a Regional Virtual Hub: In addition to creation of a physical office space with staffing to improve collaboration and exchange, a virtual hub offers a space for digital health organizations and key personnel in the health sector to communicate. It also extends the abilities of the Regional Coordinator and staff to troubleshoot and provide assistance in Kenya and other neighbouring countries where WelTel is used. There is flexibility in the design of a virtual hub based on stakeholder need, but its use to store and share documentation, and bring together knowledge holders (point of care) that really can assist one another in both implementation and delivery.

Core Activities (20%):

  • Establish an online communication platform for knowledge exchange
  • Identify each country representative(s). Includes standing country representatives as well as guest participants (such as key stakeholders or partners offering new ideas and contributions).
  • Hold monthly within-organization virtual meetings (discuss challenges, strategies, etc.) and quarterly meetings which can involve users & external stakeholders
  • Offer operational assistance (technical and limited administrative support to country programs)

Key Outputs:

  • By 2020, have an online communication platform that is used by all countries (4) using WelTel in East Africa for general communication and exchange
  • By 2020, the Virtual Hub houses documentation and virtual meeting space for all countries (4+) and representatives using WelTel in Africa
  • Administrative processes (i.e. reporting templates, auto-fill forms) on Virtual Hub complete and adopted by all countries (4+) using WelTel in Africa
  • Approx. 2-3 digital health organizations in Africa invited into shared space, with pertinent documentation made available for capacity building and collaboration
  • By 2021, active engagement with a collaborative virtual hub including WelTel sites and collaborators to build capacity, troubleshoot, streamline admin duties, and create open data exchange.
  1. Marketing & Business Development: Although WelTel’s customer base is increasing in North America and Europe, development of a sustainable revenue stream for expansion, ongoing support, and future development in LMIC remains a challenge. As country economies improve in the region, there is an increasing shift toward donor independence. For example, in Kenya, County governments have devolved health funding to select health investments most appropriate for their setting and population. Affordable interventions that can improve health outcomes are being sought. In some of the poorest areas, however, donor investments an essential component of health system strengthening and are secured as part of local and national government collaborations and guidance. To date, WelTel has relied largely on individual level partnerships through demand and convenience rather than a broad marketing strategy. Opportunities include adoption by public and private health providers. In part of its transition from research into global implementation, WelTel requires additional resources to market itself as a premier service provider in the region.

Core Activities:

  • Development of a regional scale-up strategy
  • Seek new opportunities for scale-up (customers, funding, integration, sustainability) within East Africa
  • Develop and deploy marketing materials (For conferences, trade shows, direct stakeholder and customer engagement, and online and social media presence.)
  • Seek opportunities for expansion beyond East Africa (e.g. Southern and West Africa)
  • Provide reports and analytics on scaling process within East Africa (and share within hubs)

Key Outputs:

  • By 2020, a written strategic plan for regional scale up (4+ countries, 20%+ entities metrics). This will be a living document that updates over the course of the 2 years.
  • An inventory of partners and customers existing and in the pipeline. Developed by 6 months and updated quarterly with Hub meetings. 
  • Coordinated marketing materials targeted to the region. E.g. Posters, banners, newsletters, collections of published articles and evidence, and an active online presence including social media.
  • Analytics and annual reports for funders, investors, and use in further marketing. 
  • By end of 2021, have at least 1-2 expansion projects within existing WelTel countries and 1-2 scale-up projects in new countries

B. Technology & Integration Enhancements

  1. Data & Health Systems Integration: We seek to understand and coordinate shared needs in health informatics integration at a regional level (e.g. integration into clinical settings with and without EMRs and into national and regional HMIS). The WelTel clinical service platform is already developed to include the various clinical settings including for multiple health conditions and will continue to have its development and support funded elsewhere. Ideas for clinical feature development, however, will continue to be captured during the Hub interactions. The core technology development that will be supported by this Digital Square application is to determine and develop the optimal data capture and integration strategies for the local health facility users (e.g. EMRs) as well as the higher level HMIS (e.g. DHIS2). WelTel has currently developed several data sharing agreements with implementing partners; however, additional resources will be required to ensure a clear pathway to Open Data sharing from its applications in LMIC. A clear strategy and documentation of data sharing processes and procedures will be essential to the broader adoption of WelTel’s services into the health informatics ecosystem.

Core Activities:

  • Landscape analysis of EMR and HMIS in each country

○       Identify major EMR deployments and alignment with WelTel services.  Consultation with government and collaboration partners.  A few key EMRs have been identified (e.g. OpenMRS [Kenya, Rwanda]) are examples but multiple individual facility and implementing organization level EMRs are also in use.

○       Investigate and document potential information flows between WelTel and EMRs, with alignment to national DHIS 2 flows through consultation with government, collaboration partners and technical staff.

  • Develop coordinated strategic plan for WelTel and EMR/HMIS integration

○       Depending on country context and working with collaboration partners and technical staff, develop an integration plan to implement the information flows form WelTel to facility EMR and/or national DHIS 2 implementations.  As an example Rwanda will likely require integration of several services using the Rwandan HIE, whereas Uganda and Ethiopia are earlier in their adoption of reference architectures such as OpenHIE and may benefit from more direct integration with facility EMRs.

  • Begin development of Open Data and Data sharing standards

○       WelTel currently supports access to it’s datastores via API and through simple to use full or select data exports.  However as part of the strategic plan, country requirements and integration with the broader HIE community we will evaluate which standards WelTel will implement, following the core tenets and recommendations from Principles for Digital Development.

○       Begin development of WelTel data interoperability development workstreams:

■       We anticipate at least two initial WelTel modules adhering to IHE standards - a FHIR module for communication with OpenMRS and an ADX module for direct aggregate data exchange to DHIS 2.

■       Development will be done using agile methodologies and with a user-centered design process.

○       Development of documentation

■       There is opportunity to provide a public website that indicates how WelTel plays in the broader ecosystem, and more specifically with OpenMRS/DHIS2/OpenHIE. The configuration and mapping between each of these entities, so as to line up and share data, can be disseminated in an open format.

Key Outputs:

  • By month 3 a landscape of existing and priority EMRs for developing data integration, to be updated at quarterly meetings.
  • By month 6 have a draft coordinated strategic plan for EMR/HMIS integration, finalized by end of Y1.
  • By the end of the first year, have Open Data and Data sharing standards documented and publicly posted
  • By end of Y2, have fully developed data interoperability works streams for WelTel and each country partners top EMR and HMIS (DHIS2).

Given the critical time point for investment in this sector in collaboration and interoperability initiatives, as a social enterprise existing in multiple countries, WelTel will be positioned as a use-case leader in East African mHealth reform, where considerable efforts must be made to advance targeted evidence-based services into practice while recognizing the need to meet data sharing and informatics requirements in the region.

2.  Digital Health Technologies

There are a number of mature digital health technologies involved which will be used in 3 deployment scenarios.  No changes outside of configuration will be made to OpenMRS, DHIS 2 and corresponding OpenHIE-related Components and Interoperability layer.  WelTel will include new modules for FHIR and ADX, with the specific domains and mappings aligned to the OpenMRS implementation.  Partner and government requirements will dictate which resources and actions are ultimately implemented, but will likely include certain events related to person, patient, provider, location, encounter and observation with the possibility for diagnostic report (laboratory).

  1. WelTel bi-directional with OpenMRS, federating to DHIS 2 via existing aggregation pipelines:

 

 

  1. WelTel to DHIS 2 directly via ADX:

 

 

  1. WelTel via OpenHIM to OpenMRS, DHIS 2 and corresponding OpenHIE Component Layer infrastructure:

 

 

Digital Health Atlas:

Registration with the Digital Health Atlas is in http://digitalhealthatlas.org/app/154/maps/0/0

Work Plan, Project Deliverables, & Schedule

For our full work plan and schedule of proposed activities, alongside key outputs and the associated Global Goods Maturity Model (GGMM) indicators, please see the Gantt chart here.

We assessed WelTel using the GGMM as per its present state and deployment in East Africa (Global Utility, 4/10; Community, 5/10; Software, 7/10).

WelTel ranked high for the Software core indicator, while Global Utility and Community indicators ranked lower. WelTel was designed and refined with interoperability, privacy and security principles in mind; the software is in version 3 and significant strides have been made in its usability across geographies and populations. However, strategies, documentation, and engagement with the user community requires strengthening. Digital Square offers funding for more targeted action within the Global Utility and Community core indicators, while still improving upon the software and it’s interoperability in these countries.

We assessed WelTel using the GGMM at the end of 2 years of funding, assuming completion of core activities listed in the work plan (Global Utility, 7/10; Community, 7/10; Software, 9/10). For each core indicator, the following sub indicators are directly addressed by one or more activities:

  • Global Utility: Country Strategy (Low to Medium), Country Utilization (Low to Medium), Funding & Revenue (Medium to High) 
  • Community: Developer, Contributor, & Implementor Community Engagement (Medium to High), User Documentation (Medium to High)
  • Software: Scalability (Medium to High), Interoperability & Data Accessibility (Medium to High)

We will request two years of funding to end by January 30th, 2021. Setting up of the regional hub office and hiring of key staff will occur in the first 3 months. Agreements with relevant partners will occur in the first 3-6 months. Key additional software feature development will initiate in the first 6 months and continue throughout the project period. Completion of the MNCH and TB specific modules as minimum viable products will occur in the first year and be tested and refined until the end of the project period. Business development and marketing will begin in the first 6 months and continue throughout the project period. Development of the Open Data procedures, including WelTel data linkage with the local EMRs and DHIS2 will be completed by the end of the first year, with refinements in the second year.

Project milestones will be tracked according to a Gantt chart developed with the full proposal and we will utilize a results-based accountability and management framework (RBMF). Country specific enrolment goals in terms of: a) numbers of health facilities/clinics adopting WelTel services; b) numbers of patients (direct beneficiaries) enrolled; c) numbers of frontline personnel trained; d) numbers and amounts of revenue sources for sustainability; and e) adoption of new features and services (e.g. video for TB, key indicator reporting modules linked to the DHIS2) will be monitored. We will also conduct budget impact assessments and model outcomes in terms of lives improved and lives saved.

2-Sentence Overview:

Global Good Description

WelTel is already a leading evidence-based digital health tool to support outpatient management, patient-centered care, and improve key health indicators including among vulnerable populations in in lower and middle income countries (LMIC). Our global good involves developing an affordable quality digital health service that can be scaled to the furthest reach into the population to maximize the numbers of beneficiaries and to create data flow processes that help improve critical health information exchange.

Digital Health Funded Activities

Digital Square will fund activities that WelTel have previously found difficult to secure from other sources, but that will greatly improve WelTel’s ability to scale-up and strengthen health systems in East Africa and beyond. These include creation of an East African headquarters and hiring of a regional coordinator; 2) establishment of a regional virtual communication hub to share experiences, strategies, and documentation; 3) to enhance our regional marketing and sustainable business development for scale up; and 4) develop critical health data sharing processes and standards for integration into the broader health information system in each country setting.

Community Feedback

Feedback from the Community will not be summative in nature, but rather formative.

In alignment with the Principles for Digital Development, we will be partnering with users & stakeholders throughout the process of development (Design with the User) and we will be conducting ongoing assessments of the existing ecosystems of each country and health service delivery system (Understand Existing Ecosystems). The context in which WelTel is used varies even within countries and is fluid in nature. The local complexities and nuances, and the positioning of WelTel as a tool and the organization as a leader in regional collaboration, will need to be assessed and redefined over time.

The emphasis on building community through collaborative core activities ensures integrations of users and stakeholders in process evaluation. Establishing an online communication platform for knowledge exchange, for example, involves stakeholders in determining which platform is best to use based on local preference and ease-of-use for users that may be included in virtual hub activities & collaboration. Creating strategic documents and sharing with the Community outlining processes for WelTel’s scalability and interoperability in Africa are examples of how the core activities will engage a local and broader audience.

We are mindful of the feedback that has already began during the co-creation phase of this application. Several helpful comments were made during this phase that we hope we’ve addressed in our application. We’ve reconsidered approaches and made sure to clearly define concepts that were seemingly elusive in our concept note, taking the opportunity to incorporate feedback at the onset, much like we would with feedback during the course of implementation. For answers to feedback from co-creation phase, see the Appendix.

Cases & User Stories

User type

Case Examples (Stories)

Patients

(e.g. Pregnant women, children & caregivers, HIV patients, TB patients, chronic diseases)

Clinical: A pregnant pastoralist woman (real story) registered in WelTel gets a weekly text checkin asking how she is doing. She responds “shida” and a nurse calls her and finds the patient has a new headache. The nurse is concerned and instructs her to come to the clinic and helps arrange transport. On arrival she is found to have high blood pressure and is diagnosed with preeclampsia. She is treated and delivers a healthy baby. Both mother and baby survive (who might otherwise have died if delays in therapy).

Informatics: Most government data collection systems exist at a facility level and may miss community events including complications and deaths. If this woman and baby died in the community they may not even be counted in the local or national statistics. WelTel provides a mechanism for knowing about and recording community level data that is essential for accurate data and statistics and to prevent underreporting.

Tips: Even patients with poor literacy or with the most basic phones and intermittent cellular connections can participate by keeping the service simple (easy to use) and allowing shared usage (e.g. family and community members can represent others) ensuring the furthest reach and health equity.

Digital Square Impact: 1) Through regional scaling larger numbers of pregnant women and patients enrolled in WelTel saves lives, improves key indicators, and makes community reporting of health events more accurate.

Frontline health workers

(E.g. nurses, clinical officers, counselors, community health workers)

Clinical: A busy nurse or community health worker is supporting over 1000 patients. By registering patients in WelTel the patients receive automated weekly text message checkins and other automated messaging (e.g. ANC and Immunization visit reminders, or chronic disease information) to ensure they can be supported should they have any complications or questions related to their care between visits. This has shown to improve both the quality and efficiency of HIV and MNCH care provided, since patients issues are addressed when they are needed rather than through more inefficient traditional clinic scheduled visits (supports differentiated care models). 

Informatics: Because all SMS communications and notes are captured by the WelTel platform, patient histories can be stored and referred back to for clinical care and continuity, even if the health worker changes. Information such as Expected Dates of Delivery (EDD) in pregnancy can also flag which patients (e.g. expectant mothers) should be called for follow-up. Also, any laboratory or other test results (e.g. CD4 count or HIV load) or information can be provided to patients in context at any time. This occurs routinely in practice has been prefered to providing bare lab results which can be difficult for many patients to interpret.

Tips: In rural and remote clinical and outreach settings where wifi or cellular data services are slow or nonexistent, the registering and following patients can be done completely by SMS commands. This method is fully integrated into the platform so that if a healthcare provider wishes to view the online platform for full functionality, they can do so anytime an adequate data connection exists. WelTel has run reliably in both busy urban and very remote settings with this method, which is unique and also supports health equity at the facility level since remote and smaller clinical settings can use the service.

Digital Square Impact: Through scaling, regionally harmonized training, frontline health workers work becomes more streamlined for frontline providers and extends capacity for quality care and easier capture of community level health data.

Health service providers

(e.g. Government and private health facilities, health NGOs)

Clinical: Patient defaulters are a key problem to providing optimal care. WelTel is an evidence-based tool to improve treatment adherence, retention in care, and quality of life indicators. WelTel may assist health service provider organizations in achieving health indicator targets.

Informatics: WelTel collects data and provides a connection to patients who are registered even while in the community and between visits. In addition to helping improve key indicators as above, the WelTel data can be viewed or exported to supplement data in the facility based health information systems. Because it has an open API, data can be shared regardless of which health information system (e.g. EMR) is being used, if any.

Tips: In some settings, where performance based financing is in place, the WelTel service may assist programs in reaching key indicator targets and access additional funds.

Digital Square Impact: Improved sharing of regional experiences makes implementation and scaling more efficient.

Health system administration

(e.g. Governments, Funders)

Clinical: Governments and funders are responsible for services that improve the health of the population. WelTel has been shown to be cost-effective and may therefore improve the return on investment (ROI). Modeling with PEPFAR funding has even demonstrated dramatic cost-saving due to incremental improvements in treatment adherence as offered by the users of thel service.

Informatics: In addition to improving health indicators, the WelTel service provides a unique opportunity to collect data on patients in the community which may be missed by traditional health facility level data collection mechanisms. Tips: Additional advances in analyzing text data collected by WelTel includes natural language processing (NLP) and other innovative ways to collect patient-centered data and understand patient-oriented priorities in new ways.

Digital Square Impact: Funds and activities form this grant will provide appropriate data linkages and sharing between the various levels of the health system (e.g. paper files, EMRs, DHIS2) for improved regional health informatics.

Tagging

 1. Digital Healt

2. mHealth

3.     Patient care, patient-centered care

4.     Adherence, retention, engagement

5.     HIV, TB, MNCH, primary care

6.     Health outcomes

7.     Cost-effectiveness

8.     Health system strengthening

9.     Interoperability

10.   DHIS2

11.   OpenMRS

12.   OpenHIE

13.   FHIR

14.   ADX

References:

RT Lester, … -Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. The Lancet (Editor’s choice), 2010

Lester, R. T. (2013). Ask, Don’t Tell—Mobile Phones to Improve HIV Care. New England Journal of Medicine, 369(19), 1867-1868.

https://www.scientificamerican.com/podcast/episode/text-message-outreach-improves-hiv-10-11-10/

Kazi, AM.. Lester, R.T. (2017). Assessing Mobile Phone Access and Perceptions for Texting-Based mHealth Interventions Among Expectant Mothers and Child Caregivers in Remote Regions of Northern Kenya: A Survey-Based Descriptive Study. JMIR Public Health Surveill, 30(3).

Patel, .. Lester, R.T., Marra, C.A. (2017). Economic evaluation of mobile phone text message interventions to improve adherence to HIV therapy in Kenya. Medicine, 96(7).

 

Comments

Thank you for your concept note and we look forward to your full proposal.  I recommend you expand on the software program features you propose to develop/enhance and tie these into user stories on how this will improve WelTel for clients.  Please also indicate measures of success/indicators for each of the workstreams.  As you budget, we recommend you budget per workstream and include these workstream budget figures in your budget narrative.  Finally, I recommend you address sustainability of WelTel beyond the life of this project were it to be funded, particularly the East Africa Hub Office.

Thank you Amanda. As we are developing the proposal and going through the various elements we have a few key questions related to whether we are in scope and should proceed. 

First, the Global Good Maturity model seems to reflect health system informatics and excludes digital health aimed at improving patient care. WelTel is a digital health service that is aimed primarily at patient care, so is countries would use it as part of their patient care, not 'as part of their health information system'. We believe that improved patient care should come first, and that 'informatics/monitoring' follows. Cleary some of the work we intend for this is to link the patient care data into health systems data (EMRs/DHIS2), but the WelTel software itself is designed (and proved) to improve patient care and outcomes. Please clarify if we are in scope on this.

Second: despite the  PATH Digital Square definition: Use Open Standards, Open Data, Open Source, and Open Innovation

From: Digital principles: https://digitalprinciples.org/principle/use-open-standards-open-data-ope...

..What being “open” means for your initiative will depend on practical and technical constraints, security and privacy concerns, and the dynamics of the people and networks in your space. For example, to what extent your initiative uses open source software will depend on the needs identified for your context and an assessment of which of the available options best meets those needs, factoring in their total cost of ownership.

The Global Good Maturity model does not reflect this.

This primarily seems to examine the level of open source code access, rather than either global good or level of software maturity. WelTel did open source a prior version of code via Mozilla 2.0, but found that this was not necessarily conducive to effective quality maintenance, scalability, and sustainability. In the poor remote areas we work, 'communities of developers' do not exist, and to meet SDGs and help close the digital divide we need well packaged and supported software solutions that are well supported and with quality assurance that cannot be affordably acquired by open source code - nor can a sustainable business model. We are working through best 'good licensing practices', which may include some degree of open source (not likely WelTel SaaS code, but certainly other know-how and most data). The Global Good maturity model does not fit with what we know about scalability and sustainability, nor with Square's own (more flexible and appropriate) definition of "open" above. Please indicate if we are in scope on this.

Thank you!

Richard

The description of the consortium team and the description of a timeline refer to integration with EMR and DHIS2 (presumably Tracker) systems. However, in the list of activities, there is no reference to a task/activity that describes specific work to establish this integration. What does this integration look like? Do you envision a direct interoperability or the use of an HIE?

The project team also emphasizes the positioning of WelTel as a clinical intervention. This is of course appropriate. However, the objectives of many EMR implementation is also as clinical intervention even if conventional clinical documentation is often mandated/prioritized.  In an intervention that combines both an EMR as the facility-based clinical information system and the “frontline digital health service” as implemented by WelTel, how will you facilitate proper impact evaluation of both components?