Neal Lesh Computer science applications to improve health delivery in low-income countries.

My Story Mid-thirties computer researcher seeks more fulfilling career. Goes back to school then off to Africa. Discovers things are more simple and more complex than he originally imagined. Can't imagine doing anything else...

Outline Background The simplicity and complexity of global inequity Two examples Patient record systems for AIDS treatment Medical algorithms on handhelds Conclusion

Risk Factor for surviving the Titanic. % survived Poverty as a

Global Health

Simple Story $$$$$$$$$$$$$$$$ $ Infant mortality: 5 per 1,000 births Maternal mortality: 8 per 100K births Life expectancy: 78 years Infant mortality: 95 per 1,000 births Maternal mortality: per 100K Life expectancy: 45 years

Simple Story $$$$$$$$$$$$$$$$ $

Simple Story $$$$$$$$$$$$$$$$ $$$$$$$$$$$$$ $$$$ Infant mortality: 95 per 1,000 births Maternal mortality: per 100,000 b Life expectancy: 45 years

Simple Story “We are the first generation that can end poverty.” - Eveline Herfkens, UN Millennium Campaign

Complexity Corruption, careerism, tax write-offs 5-star poverty alleviation meetings Unintended consequences, e.g., paying volunteers Imperialism & foreign experts “If you want to build a ship, don't drum up people to collect wood and don't assign them tasks and work, but rather teach them to long for the endless immensity of the sea.” – Antoine de Saint-Exupery

Information as Care Study: rigorous application of standard treatment protocols reduced in-hospital mortality in children’s malaria cases by 50% Clinician’s complaint: where are my lab results?! Patient Knowledge Example: five danger signs for seeking care during and after labor.

Outline Background The simplicity and complexity of global inequity Two examples Patient record systems for AIDS treatment Medical algorithms on handhelds Conclusion

One year later AIDS Treatment in Rural Rwanda

One year later Improving Health Systems

One year later Connecting to the Internet

Electronic Medical Record (EMR) Patient Monitoring Reports Clinicians & Patients Managers EMR Staff Paper forms Program Monitoring Reports Funder & government reports $ Re-allocate resources

Patient Monitoring

Missed-Visit List

ICT task: satisfy reporting requests

OpenMRS Open source framework for medical record systems

Data Quality Mistyped IDs Missing & conflicting data Backlog Potential solution: point-of-care systems

Harder than it looks! But Only one program I know produced these Have not eliminated dosing errors, even there Producing helpful reports is only first step

Challenges & Opportunities Keep up with demand Increased impact on decision making – Inform to Improve (I2I) teams Integration of lab and pharmacy components Detecting important trends in data

Outline Background The simplicity and complexity of global inequity Two examples Patient record systems for AIDS treatment Medical algorithms on handhelds Conclusion

Rural Dispensary in Tanzania

Standardized Care (IMCI)

Tanzania: underfive mortality was 13% lower in the two IMCI districts Source: Schellenberg J et al Full IMCI in HF End of study 13% difference 95% CI: -7%, 30% Significant impact on stunting

Deploying IMCI IMCI – Shown to reduce mortality and morbidity – Adopted by over 80 countries But uptake not as good as hoped – Training expensive – Correct use tapers off over time – Supervision challenging

Why Automate IMCI?

Improve adherence Improve supervision Easier to update More sophisticated protocols Reduced training

Field Work Results to be published in CHI’08

How Automate IMCI?

Exploratory Study Pretesting & rapid iteration Structured interviews Observed trials w/ additional clinician to: – Ensure safety – Record adherence to IMCI – Record time

Viral Training

Key Findings Must be – Fast – Flexible – Improve adherence to IMCI Must address intentional deviation from IMCI – Temperature, respiratory rate – Advice

Adherence Results Investigation Current practice adherence e-IMCI adherence p-value Vomiting66.7% (n=24)85.7% (n=28)- Chest indrawing75% (n=20)94.4% (n=18)- Blood in stool71.4% (n=7)100% (n=3)- Measles in the last 3 months 55.6% (n=9)95.2% (n=21)< 0.05 Tender ear0% (n=1)100% (n=5)- All61% (n=299)84.7% (n=359)< 0.01

Triaging patients on treatment for AIDS (Study ongoing in South Africa)

Outline Background The simplicity and complexity of global inequity Two examples Patient record systems for AIDS treatment Medical algorithms on handhelds Conclusion

Key points – Must understand context – Much potential, many challenges – Keep it simple Challenges – Evaluation, local ownership, I2I, duplication of effort, …

Thank you!

EXTRA SLIDES

What are we going to do today, Brain? The same thing we do every day, Pinky…. Make a plan to TAKE OVER THE WORLD!!!!!

Handhelds Small screen, can’t run new programs Medium screen, can run new programs Large screen, stylus, can run new programs No cellular Cellular Relatively common, rather inexpensive. Becoming more common and less expensive Expensive now. Are getting cheaper or better? Relatively inexpensive, but is market fading? XX

Public Health Puzzle CanadaMexico Deaths per 1000 per year (2003 est.) Is Mexico healthier than Canada?

Global Health Puzzle

Social Messaging Over Cell Phones

Lab Systems

EZ-Mapping Lots of need for mapping and tracking in NGO work. Little time to devote to it. Need super simple system aimed at most important needs.

SMS Surveys