Insights into the design, development and implementation of a novel digital health tool for skilled birth attendants to support quality maternity care in Kenya

By Paul Amendola, Executive Director, VecnaCares

Reference: Bartlett LAvery LPonnappan P, et al, Insights into the design, development and implementation of a novel digital health tool for skilled birth attendants to support quality maternity care in Kenya,

 

The appetite for and ability to collect accurate digital patient-level data in low-resource settings has fueled numerous massive global health initiatives.  Digital systems have enabled NGOs and Ministries of Health to regularly report “big data” health system performance metrics about the millions of people in their catchment populations; the hundreds of thousands of anti-malarial treatments provided or children supplemented with vitamin A; and the tens of thousands of deliveries assisted by skilled birth attendants. As impressive as these large numbers may be, the question that is less often asked is “How much of that big data is actually helping us do better?”

The answer to that question can often be found in an assessment of where those big numbers originate. Most big numbers are the product of many smaller numbers, collected by health workers tasked with recording a simple interaction with a patient, a pregnant woman, a community member, or a survivor. Donors, government ministries, agencies and academic partners regularly cascade requests for data that multiply and complicate the simple interaction into a complex, and often redundant, set of data requirements for the same singular interaction. The reality is that the resources, operations, quality, and overall impact of any organization rely on the reliability and quality of those recorded interactions.

Unfortunately, the widely held appetite for these numbers is not matched with adequate funding or infrastructure to enable high-quality data collection.  Data collectors complete hundreds of data entries on multiple forms. Ensuring a reasonable level of data quality needs careful training, consistent supervision, and critically, well-designed and reliable systems. However, the limited resources designated for measurement and monitoring are often woefully inadequate, a problem further amplified by numerous uncoordinated data requirements from donors.  A promising solution to produce meaningful data is the thoughtful and measured development and introduction of practical digital technology platforms. In its best use case, such technology would provide the foundation of person-level digital information systems that can be used to accurately collect and use   data in at two critical levels: in real-time to improve individual patient outcomes, and aggregated to monitor the health status of a population, i.e. the big numbers.  With increased global availability of tablets, smartphones, and laptops, it is now possible to accurately collect the key building block of any information system – source data at the individual level. Mobile phone penetration has finally exceeded 90% in low- and middle-income countries. For health information systems specifically, patient-level data that is accurately collected and structured provides actionable information for better allocation of resources, better understanding of population health, and better health decisions for patients.

With this vision MSD for Mothers convened a set of partners including VecnaCares, Johns Hopkins University and Scope to design and develop an advanced maternal health solution to support clinical intrapartum care – these collaborative efforts culminated in the genesis of iDeliver – a mobile, digital, point-of-care tool for skilled birth attendants (SBAs) in limited resource settings. iDeliver was developed on an open-source standards-based framework, allowing Ministries of Health to adopt, and eventually own, an advanced electronic medical record (EMR) that aligns with most national e-health strategies.

Digital uptake is more prevalent in high-volume and urban hospital networks.  Low-resource settings provide unique challenges to adoption: frequently there are a low number of care providers serving a higher number of patients, supervision is conducted less regularly due to travel times, and current clinical guidelines might not be readily available.  As a result, the guiding principle of iDeliver has been to develop a system to better inform clinical decisions and increase the quality of maternal and perinatal care throughout the continuum of pregnancy, labor and delivery and the postpartum periods. Adoption of digital systems in low-resource settings has two primary potentially massive benefits to users: active system engagement to increase the adherence to clinical guidelines and the provision of an increased level of patient-level situational awareness.  By focusing on those core outcomes, iDeliver has a number of key new and distinguishing functionalities including (a) clinical decision support in a concise, practical checklist format to guide providers through correct diagnosis and treatment protocol adherence (consistent with World Health Organization (WHO) standards); (b) real-time acuity level calculation to identify the most critical patients and provide reminders on the timing to re-assess the patient; (c) EMR capacity with auto-generation of Local MoH reports; and (d) built-in training clinical training tools. These comprehensive functions were developed using human-centred design methods to optimize useability.

iDeliver has evolved since the initial deployment with significant improvements in both system adoption and increased levels of data completeness.The design, development, and deployment practices of iDeliver are consistent with the fundamental recommendations of the WHO Global Strategy on Digital Health in 20201, that has helped support its successful creation and scale. iDeliver was designed to evolve – multiple workshops were carried out throughout East Africa and India to collect feedback from end-users to rapidly iterate the design and functionality. Safety and efficacy have been key fundamental driver of iDeliver – clinical guidance has been evaluated with multiple expert clinical staff throughout John Hopkins University, clinical administrators throughout East Africa, and the iDeliver Advisory Board. Efficacy was maintained by thorough and careful analysis of key indicators and feedback provided by clinic end-users. Specifically, the user interface design was conceived and refined through constant direct feedback from mid-wives, nurses, and clinicians using the system over time. Indicators were created and tracked to measure efficiency gains, uptake, and health outcomes.  The acceptability and feasibility of iDeliver have been closely monitored and have been the foundation for several iterations. iDeliver was designed with the end-user – meaning it is one of the first open-source systems to accurately reflect the daily activities of care providers while providing a real-time system for collection, analysis, and feedback. The system was rigorously tested for acceptability across different settings and within different facility types from rural primary care centers to large urban high-volume hospitals. Lastly, the cost-effectiveness of iDeliver has been one of the guiding principles of the strategic development. iDeliver is designed to demonstrate the immediate and long-term return on investment for facilities to transition to digital records. The financial return on investment (ROI) encompasses not only the reduced operational cost, but also the reduced cost of providers not following clinical guidelines and spending increased time on-boarding new clinical staff members to use the system.

iDeliver, is an example of a technology solution having an impact across a health system – from patients to providers to ministry stakeholders. The investments, led by MSD for Mothers and supported by other donors, has allowed best practices for development and deployment to be followed with a result in maximizing the impact. Currently, a hospital in Tanzania has used iDeliver for over 16,000 births with a 100% adoption rate with end-users.  At VecnaCares, and with our partners, our fundamental philosophy is that the right digital tools, deployed correctly, do have the potential for sustainability and impact – in any setting.

 

Conflict of Interest: None declared

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