e-IMCI: Improving Pediatric Health Care

in Low-Income Countries

University of Washington

Brian DeRenziQuals Talk

November 19, 2007

e-IMCI

Project PDA-based decision support for clinicians at the

point of care Increase quality of care delivered

Result Significantly increased adherence to medical

protocol without substantially increasing patient visit time

Contribution Adapted code base to implement the protocol for

pediatric health care Ran two-month field study in rural Tanzania to

pilot the system and determine how it can help

Outline

Motivation Introduction Background on Project Integrated Management of Childhood

Illness (IMCI) e-IMCI Field Study Results Future work Acknowledgements

Motivation

This year almost 10 million children will die before reaching the age of 5

Most live in low-income countries 10% of infants die during

their first year, compared to0.5% in wealthy countries

Almost 2/3 could be saved by the correct application of affordable interventions

Motivation

Every 6 seconds a child dies unnecessarily

Introduction

UNICEF, WHO and others develop medical protocols e.g. Integrated Management of Childhood

Illness (IMCI) Clinical guidelines for busy facilities Easy to use for lowly-trained health

workers

Introduction - IMCI

Originally developed in 1992

Adopted by over 80 countries worldwide

Children 0-5 years old Common illness

Cough Diarrhea Fever Ear Pain Malnutrition

Eacer

IMCI

IMCI Barriers

Expense of training ($1150 -$1450) Not sufficient supervision Chart booklet

Takes a long time to use Natural tendency to be less rigorous Social pressure

Result - not often followed in health clinics

Related Work

Automating procedural tasks Using mobile devices can help under high workloads

Harvard University Program on AIDs (HUPA) Project Designing medical protocol in South Africa

Decision support in India TRACNet, OpenMRS, IHRDC study Gary Marsden Computable protocols

GLIF Artificial Intelligence

Expert systems, Probabilistic systems

e-IMCI

Put IMCI protocol on PDA Guide health workers step-by-step Potential benefits

Better adherence to protocol Easier and faster than book Data collection is a by-product of care Can handle more complex protocols Interface with other devices and EMR Reduce training time and cost Strong supervision

How the project started and how I got involved.

Background

D-Tree International

Medical algorithms on mobile devices Help over-burdened health workers Gather data from the field Work with governments to implement

sustainable programs HUPA project

HUPA Project

Started in Cape Town HIV screening

algorithm Counselors can quickly

determine if patient needs to see doctor

Huge shortage of doctors

29.1% national HIV prevalence1

Less than 1% in US1 http://www.avert.org/safricastats.htm

South Africa

Worked with Right To Care Non-profit at Helen

Joseph Hospital Second site for HUPA

project Gained experience with

the HUPA code Delivered PDAs,

established workflow Introduced to health

facilities and field work

South Africa

Tanzania

Worked with IHRDC Met with the Tanzanian government and

other NGOs

Integrated Management of Childhood Illness.

IMCI

IMCI Example

IMCI Example

IMCI Example

IMCI Example

IMCI Example

Electronic delivery of IMCI.

e-IMCI

e-IMCI Interface

e-IMCI

Implemented subset of IMCI protocol for pilot study

Contains cough, diarrhea, fever and ear pain questions and treatment

First visit, ages 2 weeks to 5 years

Real clinicians. Real patients. Real world.

Field Study

Mtwara, Tanzania

Worked with IHRDC in Mtwara, Tanzania Southern Tanzania Rural

Subsistence farming Fishing

Piloted e-IMCI at a dispensary

Study Design

Started with five clinicians Four clinicians completed study Goals:

Discover usability issues

Discover if e-IMCIincreases adherence

Determine how e-IMCI affectspatient visit

IMCI Protocol Use

Ideal case Follow paper chart booklet for every patient

between 0-5 years of age “Current practice”

Treat patients from memory, occasionally referencing the chart booklet

e-IMCI trials Treat patients using the e-IMCI software

system

Study Design

Started with some pre-trials to fix major bugs

Semi-structured interview of all clinicians

Observed 24 “current practice” IMCI sessions

27 e-IMCI sessions Exit interview for

each clinician

Study Design

Real Patients, not actors

Used same data collection forms for current practice and e-IMCI

Pairwise design Basic pilot, no

randomization

Trials per Clinician

1 2 3 4 5

Number of “current practice” trials

5 5 5 5 4

Number of e-IMCI trials 13 - 6 4 4

Clinician

Numbers, reactions and lessons.

Results

Adherence

Measured adherence using 23 items IMCI asks the practitioner to perform

e-IMCI significantly improved adherence to the IMCI protocol p < 0.01 p < 0.01

Adherence: The Numbers

Investigation

Current Practice Adherence

e-IMCI Adherence

p-value

Vomiting 66.7% (n=24)

85.7% (n=28)

-

Chest Indrawing

75% (n=20)

94.4% (n=18)

-

Blood in Stool

71.4% (n=7)

100% (n=3)

-

Measles in Last 3 Months

55.6% (n=9)

95.2% (n=21)

<0.05

Tender Ear

0% (n=1) 100% (n=5)

-

All 61% (n=299)

84.7% (n=359)

< 0.01

Adherence: Advice Numbers

Clinical Officer

Current Practice Adherence

e-IMCI Advice Adherence

p-value

1 20% (n=15)

76.9% (n=39)

< 0.01

3 26.7% (n=15)

66.7% (n=18)

< 0.05

4 80% (n=15)

100% (n=12)

-

5 100% (n=12)

73.3% (n=21)

-

All 56.9% (n=72)

77.4% (n=84)

< 0.01

Timing

Clinical Officer

Average Length of Current Practice Patient Visit (minutes)

Average Length of e-IMCI Patient Visit (minutes)

95% Confidence Interval of e-IMCI Minus Current Practice

1 16 (n=5) 13 (n=13) -2.1 to 7.9 †

3 6 (n=5) 8 (n=6) -5.5 to 1.0 †

4 7 (n=5) 9 (n=4) -5.7 to 4.7 †

5 19 (n=4) 14 (n=4) -2.1 to 13.1 †

Total 10 (n=24) 11 (n=27) -2.4 to 2.4 ‡

† unpaired t-test, ‡ paired t-test of 18 trials

No substantial increase in patient visit time

Clinician Reaction

Unanimously cited e-IMCI as easier to use and faster than following the chart booklet

Clinician Reaction

Wanted to use the system for Care Treatment Clinic

Liked being able to review answers to questions

Asked to be in future studies “Sometimes since I have experience

[with IMCI] I will skip things, but with the PDA I can’t skip.”

Would “use a combination” of current practice and the e-IMCI software and would never need to refer to the book

Lessons Learned

Limitations Question Grouping Threshold Problem

Requirements Flexibility

Incorrect IMCI otitis externa

Local Preference Antibiotic Lab use

Conclusion

e-IMCI significantly improves adherence to IMCI protocol

Does not substantially lengthen the patient visit time

Positive reaction from clinicians, but room for improvement

Large number of interesting enhancements for the future

Where we’re going.

Future Work

e-IMCI for Training

Current training lasts 11-16 days

Costs $1150 - $1450 per person

Using e-IMCI to train, could reduce time and cost

No need to train the protocol as in-depth

Tutored mode

User-Driven Model

“Expert” mode Allow users to

decide what investigations to perform

Flexibility will encourage long-term use

Merge with current system-driven approach to ensure correct care

Deploying Protocols

Interfaces for tutor, guided and expert modes

Automatically generate interfaces for different platforms

Maintain consistent look and feel

Community Outreach

Take e-IMCI outside of the health facility Travel village-to-village to collect health

census information and deliver care

Acknowledgments

Neal Lesh, Marc Mitchell, Gaetano Borriello, Tapan Parikh, Clayton Sims, Werner Maokola, Mwajuma Chemba, Yuna Hamisi, David Schellenberg, Kate Wolf, Victoria DeMenil, D-Tree International, Dimagi Inc., the Ifakara Health Research & Development Centre, the Ministry of Health in Tanzania and the clinicians in Mtwara for their support and contribution to this work.

Questions

Just in case.

Extra Slides

The vision.

Introduction

What others have done.

Related Work

IMCI in Tanzania

Adapted and adopted by Tanzania in 1996

National policy Main component is a medical protocol

followed by health workers at the point of care

Pre-Grad School

Volunteered with American Red Cross after Hurricane Katrina

Volunteered with International Service Learning to deliver medical supplies in rural Tanzania

Introduction

Digitize protocol to make it easier to use