Mobile based decision support system to help the implementation of integrated community case management in Ethiopia.

1. Mobile Based Decision Support System to
Improve Child Health Care (mobile e-Health System)
Andualem Workneh,
andufree@gmail.com
June – 15, 2013
For Creatic4Africa research scholarship program
organized by
CTIC Foundation

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Outline
1. Introduction
2. Statement of the problem
3. Objective
4. Related Work
5. Proposed System
6. Implementation
7. Next phase – in the target environment
8. Conclusion

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1. Introduction
 In Ethiopia, a primary health care unit consist of Health centers and
Health posts (HPs).
 In each health post, Health extension workers (HEWs) are assigned to
give health service to the community.
 Responsible to execute different health packages including
Integrated Community Case Management (ICCM) program …

4. Introduction …
 ICCM program is an integrated management of childhood and
newborn illness at the health post level.
 The main objective of ICCM program is to reduce child mortality and
morbidity by giving better health service to children and newborns.
 Focuses on addressing leading causes of child mortality: pneumonia,
diarrhea and malaria
 And also other medical cases (malnutrition, immunization ....)
 ICCM medical guideline is used for ICCM service provision
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2. Statement of the problem
 While giving ICCM service to children, HEWs are expected to always
use ICCM guideline. High adherence to usage of the manual guideline
is very much required.
 Performing diagnosis and treatment without using the guideline has a
risk of committing clinical error
 Medical procedures are not easy to remember (especially for less
experienced HEW)
 But in the current practice, less adherence to guideline usage is
observed

6. Statement of. Cont.
 Poor medical data reporting
and documentation were also
observed
 Child’s medical case is
recorded in a paper-based
form
 Incompleteness and
inconsistency in the medical
records were observed.
 Giving continuous supportive
supervision to HEWs is also a
challenge
 Supervisors can not reach all
HEWs regularly
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Statement of. Cont.
 In the current system, paper based clinical guideline is
used together with a registration book
Figure 1: Paper based ICCM Clinical guideline, to assess and classify
breathing problem

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3. Objective
 General Objective:
 It is to design and develop mobile based decision support system
to help HEW to give better service in ICCM program
 Specific Objective:
 Conduct requirement gathering (interview and field observation)
 Model the ICCM guideline to electronic form with a selected
modeling tools/language
 Design the proposed system based on the requirement
 Develop a prototype and
 Pilot test the prototype in the field

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4. Related work
 e-IMCI:
 e-IMCI is a PDA based decision support system that guide
clinicians through a series of preprogrammed algorithms based
on IMCI protocol.
 Help to achieve
 High adherence to the protocol
 Reduce skipped steps and branching errors
 It is pilot tested in Tanzania
 Electronic Decision Support in the treatment of AIDS
patients in South Africa:
 It is to support screening of HIV+ patients to determine where
they can get treatment and follow-up
 An electronic HIV treatment guideline is used
 This system is pilot tested in South Africa

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5. Proposed System
 Mobile based DSS system
is proposed.
 It has a client-server
architecture with decision
support, data collection
and data reporting
modules
 The system has the
following hardware-
software mapping
Figure 2: Hardware-software deployment diagram for the proposed system

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6. Implementation
 The ICCM guideline is modeled with an open
source business process management suite called
jBPM.
 The electronic ICCM guideline is stored as BPMN 2.0
specification.
Figure 3: Modeled clinical guideline, to assess and classify
breathing problem

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Implementation Cont.
<subProcess id="_1" name="የአተነፋፈስ ችግር ምርመራ" >
<startEvent id="_1-1" name="Start" />
<exclusiveGateway id="_1-2" name="Gateway" gatewayDirection="Diverging" />
<scriptTask id="_1-3" name="የአተነፈፍስ ችግር (Birth Asphyxia)" >
<script>kcontext.getKnowledgeRuntime().setGlobal("classification_1", "የአተነፈፍስ ችግር (Birth Asphyxia)");</script>
</scriptTask>
<scriptTask id="_1-4" name="የአተነፈፍስ ችግር የሌለው (No Birth Asphyxia)" >
<script>kcontext.getKnowledgeRuntime().setGlobal("classification_1", "የአተነፈፍስ ችግር የሌለው (No Birth Asphyxia)");</script>
</scriptTask>
<scriptTask id="_1-5" name="የአተነፈፍስ ችግር ህክምና" >
<script>treatment = "&lt;?xml version='1.0' encoding='UTF-8'?&gt;&lt;Treatment&gt; &lt;Task&gt; ሪሰሲቴት ማድረግ ጀምሪ .....
&lt;/Task&gt; &lt;/Treatment&gt;";
kcontext.getKnowledgeRuntime().setGlobal("status", "red");</script>
</scriptTask>
<scriptTask id="_1-6" name="የአተነፈፍስ ችግር የሌለው ህክምና" >
.....
</script>
</scriptTask>
....
<sequenceFlow id="_1-2-_1-3" sourceRef="_1-2" targetRef="_1-3" >
<conditionExpression xsi:type="tFormalExpression" >return isNotBreathing == true || hasDifficultBreathing == true ||
(breathCountPerMinute &lt; 30);</conditionExpression>
</sequenceFlow>
<sequenceFlow id="_1-2-_1-4" sourceRef="_1-2" targetRef="_1-4" tns:priority="1" >
<conditionExpression xsi:type="tFormalExpression" >return isNotBreathing == false &amp;&amp; hasDifficultBreathing == false
&amp;&amp; (breathCountPerMinute &gt;= 30);</conditionExpression>
</sequenceFlow>
.....
</subProcess>
 Modeled ICCM guideline in BPMN 2.0 specification
Figure 4: Modeled Clinical guideline in BPMN 2.0

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 For the client-side, Android based smart phone was
selected. Android is chosen because
 It is based on an open-source platform and has better
localization capability,
 Availability of tools like ODKCollect, a mobile based data
collection framework, and an Amharic virtual keyboard for
data entry.
 For the server-side, Django web framework were
used to develop the web-based application.
Implementation Cont.

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Implementation Cont.
 Client-Side system
 Assessment – Classification –
Treatment (based on the
electronic guideline)
 Edit filled medical records
 Send filled medical record to
server
 Download new rule, forms, and
feedbacks given from server
 Delete existing medical records
Figure 5: Client side system which is running on a mobile phone. List of client-side
functionalities

15. Implementation Cont.
 Assessment:
 Questions for
assessing medical
case of the child is
displayed one by one.
 Xform technology is
used to develop the
form
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Figure 6: Assessment questions (a) open-ended question with Amharic virtual
keyboard. (b) Close-ended question
a. b.

16. Implementation Cont.
 Suggested medical
case classifications
and treatment
procedures:
 The mobile application
classifies the medical
case of the child based
on assessment made
and the electronic
medical guideline.
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a. b.
Figure 7: (a) suggested case classifications . (b) suggested treatment procedures for a
particular medical case

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Implementation Cont.
 Server-side system:
 Medical history of the child is compiled at the server side. For this purpose, ID is given to
each child to uniquely identify each child and it medical encounter
Figure 8: Web interface for the reported medical case

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7. Next phase - in the target environment
 Involving participating stakeholders to pilot test the
system in selected HPs
 Training HEWs on how to work with the system, and
 Run the system for specific period
 Perform usability testing with HEWs
 Evaluating the system and make adjustments based on
the experience gained
 And proceed with system deployment to other HPs

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9. Conclusion
 With the system proposed, it is expected to achieve
 High adherence to usage of ICCM guideline
 Better medical record reporting, storage and documentation
 Better means to give supportive supervision to HEWs from
remote by sending feedback to HEWs
 For the future, the system can be customized or
extended
 to run on other mobile platforms;
 to support other regional languages; and
 to support other related health programs.

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Thank you