1. eCompliance: A game changer that can scale
TB care internationally and prevent MDR TB
© Operation ASHA
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2. India- the emerging superpower?
Drug Resistant TB
in India
More than 100,000
estimated cases of
drug resistant TB in
India, less than 3,000
identified.
12 cases of extremely
drug resistant TB
(XXDR or TDR)
recently found in
India.
In a recent study, only
3 out of 106
practitioners issued
an appropriate
prescription for drug
resistant TB.
MDR-TB Treatment costs
50-200 times more than
normal treatment
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3. 100% DOTS coverage?
“DOTS alone is not sufficient to curb the TB epidemic in
countries with high rates of MDR-TB.”
- Stop TB Working Group
“Electronic datasets are needed to facilitate accuracy and analysis
of data.”
-WHO (2011)
Horrifying Scenario
 2015: 1.3 million MDR cases, needing $16 billion
 2050: 50 million TB cases.
 2050: 10 million deaths, 2 million of these will be by MDR-TB
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4. Solution- a local, deep model with community empowerment &
eCompliance for low cost and high impact model
• Accessible DOTS - Strategically locates TB centers in
convenient, high-traffic areas
• Community members hired as providers
• Rigorous Training
• Performance based incentives
• eCompliance biometric terminals.
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5. eCompliance- “Turning the Tap Off” on MDR-TB
PRIMARY OBJECTIVE - To ensure accuracy and adherence
PROBLEM
SOLUTION
•
•
•
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• Finger print confirm the presence
of a TB patient as well as the staff
• Patients/ staff scan their
fingerprint at the treatment
center
• This creates indisputable evidence
of patient interaction, initial
house visit and follow up of each
missed dose
• One cannot ‘fudge’ a fingerprint!
Unsupervised doses being given
Missed doses and default
Missed doses are not tracked
Time lag between missed dose
and follow-up
• Inaccurate record keeping
• Data fudged deliberately
• Absenteeism among staff
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6. Workflow with eCompliance
Patients are registered by scanning fingerprint
At every visit, patients scan finger, creating a verifiable log
of patients who were present
• Runs on commercially available, ‘off-the-shelf’ components
• An inexpensive android phone
• A commercially available inexpensive finger print reader
• Software developed by Operation ASHA, with initial support from Microsoft Research
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7. Features of eCompliance
• Color coding shows that a patient has been successfully
logged in
• The simple interface uses a minimal amount of text
• Can be easily translated into other languages
• Geo-tagging of all Supervised Doses
Providers can quickly identify which patients have
• missed their dose
• So they can follow up, within 48 hours, provide dose,
further counseling and convince the patient to join the
therapy again.
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8. Front End
How eCompliance Works
The Front End
•
eCompliance Tablet
Patients, Health Worker
& Program Manager
SMS
Back End
Uses only off-the-shelf
components
 A fingerprint reader
 An Android Tablet
The Back End
•
•
•
Electronic Reporting
System
SMS Gateway for Sending
Alerts
Electronic Medical Record
System
Central Database
Online SMS Gateway
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9. eCompliance Guru: Web-based reporting system at the back-end
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10. Replication by Researchers at Columbia University/ Millennium
Villages Project in Uganda
Third party replication by Columbia University/ Millennium Villages in UGANDA in June 2012
• Outstanding results: Death + Default rate down to zero from > 16% in the preceding year
CHWs in Uganda being trained on eCompliance
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11. eCompliance: Implementation
Results
•
•
•
•
Default <3%
Over 6,777 patients enrolled so far
Over 2,68,398 visits logged
Over 5,000 visits logged every month
Lessons Learned
• Patients are
not hesitant to give their fingerprints
• Patients perceive technology as a sign of high
quality of treatment
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Terminals used in South Delhi since 2010
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Terminals installed in Bhiwandi, Jaipur and Mumbai centers in since 2012
Terminals installed in 5 cities in MP (Bhopal, Jabalpur, Gwalior, Gwalior Rural, Indore, Sagar) and 3
cities in Chhattisgarh (Raipur, Bilaspur, Durg, Bhilai) and Bhubaneshwar in Odisha
84
159
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Total no. of terminals installed by the end of Aug 2013
Of which so many Android terminals have been installed in South Delhi and Dharavi , Mumbai since
July and Oct 2013
Of which 3 terminals were installed in Uganda in 2012 and 2 in Dominican Republic in Jun 2013
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12. The Key Benefits of eCompliance
PATIENT AND COMMUNITY LEVEL
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Positive impact on the psyche
Improves motivation
Seen as dedication towards quality treatment
Interest generated by technology intervention in disadvantaged areas
Re-enforces belief in the government and DOTS
Indirect benefit- discussion of health issues
AT LEVEL OF FIELD STAFF
•
•
•
•
•
•
•
•
•
Ensures integrity of DOTS: eliminates unsupervised doses, which are otherwise the norm
across the world
Eliminates human errors in management of DOTS. For example, if a patient comes on the
wrong day, eCompliance automatically reminds the counselors and prevents such
occurrences
Improves skills
Makes counseling easy, ie. easier to convince patients
Accurate reporting and up-to-date intelligence
– Eliminates human error
Saves time spent in going through paper records
Real-time records allows counselors to target counseling
Produces all reports automatically.
The above results in 30% improvement in productivity and reduction of costs, which
more than pays for the cost of eCompliance terminals.
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13. The Key Benefits of eCompliance
MANAGEMENT LEVEL
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•
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Accuracy of records
Transparency
An accurate platform for monitoring and evaluation of the core
program
– Eliminates absenteeism, late coming of staff
– Prevents tampering with patient data
Transparent treatment supervision
Ensures proper payment of performance based incentives
THE PUBLIC HEALTH PERSPECTIVE
•
•
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ENSURES DOTS is being delivered
Halts the development of drug resistance due to default.
Provides unlimited quality data for future research
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14. Challenges and the solutions
STAFF
 Fear of micro-monitoring
 Fear of losing jobs to computers
 Fear of theft, breakages
PATIENTS
 Fear of electric shock!
TECH TEAM
 Accuracy of recognition of finger-prints
 Computational ability
- Privacy of patients and data
- Maintenance
- Software and hardware failure, viruses etc
- Need based ongoing system analysis
- Security measures needed to prevent tampering
- Reconciliation of data
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15. Cost Effectiveness
Component
Cost
Android Tablet
$ 140 (Rs. 8,500)
Fingerprint Reader
$ 65 (Rs. 4,000)
Internet Plan (per year) $ 40 (Rs. 2,400)
Total cost of each eCompliance terminal = $245 (Rs. 14,900)
Cost per patient = $2.66 (Rs. 162), which is more than offset by increased
productivity (each unit will treat 92 patients over 2 years: average at OpASHA)
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16. Immediate need: multilevel use of eCompliance
This will incorporate
1. All nationwide DOTS centers
2. Microscopy centers
3. Referral labs
4. Public hospitals
5. Drug sellers
6. Quacks
7. Pharma-companies
8. Any individual/ organization
that is involved in TB control
Expected Benefits
1. At all levels- ensure complete, comprehensive, real-time and
transparent data
2. Microscopy centers- will send alerts to CHWs, public hospitals
to prevent “loss” after detection
3. Public hospitals
4. Referral labs
5. Drug sellers - incorporate in DOTS to prevent misuse of drugs
6. Incentivize patients ( for example a10 cents talk time for each
dose taken or a regularly increasing incentive!)
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17. Conclusion- the way ahead
Develop eCompliance software further for
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System analysis for daily dose regimen
Adherence for MDR-TB,
ART
Integration with MCH, midday meals etc
NCD, especially integration with DM
Zero literacy areas (use icons and audio tracks)
The fight goes on…
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