This document provides an overview of a session on using mobile tools to support the continuum of care in global health projects. It introduces Dimagi, an organization that creates open-source mobile health tools, and discusses how mobile technologies like SMS, voice, and apps can be used at different levels of the health system from community health workers to clinics. Examples of using these tools for referral tracking and longitudinal patient care are presented. The document concludes with breakout activities for attendees to discuss challenges and opportunities for improving referral processes, data reporting, and integrating clinic and community health worker systems using mobile tools.

1. 0
mHealth Across the Continuum of Care:
Strategies for Implementation
CORE Group
Spring 2015 Global Health Practitioner Conference
Alexandria, VA

2. 1
Agenda
 Introductions
 Background: mHealth Toolkit & Project Examples
 Breakout Activity
 Report Out/Wrap Up

3. 2
Session Objectives
 Provide examples of how mobile tools already support
the continuum of care
 Recognize unique challenges and opportunities for
mHealth across the continuum of care
 Develop a specification for an mHealth program that
could support your health project
Fair Warning: We speak tech better than health –
we’ll ask you to help us on the health part!

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About Dimagi
 Mission: We deliver open and innovative technology to help
underserved communities everywhere
 Created out of Harvard and MIT Media Lab
 Business units in Cambridge (USA), New Delhi (India), Cape Town (South
Africa), Maputo (Mozambique), Dakar (Senegal)
 In-country staff in Thailand, Guatemala, Burkina Faso, Zambia
 Leaders in Open-Source product development and Software-as-a-
Service (SaaS) support for mobile technology
 Multi-disciplinary team of 100+ with engineers, field implementers,
consultants, scientists, public health experts, and physicians
 10+ years of experience with over 150+ ICT projects across
numerous sectors and technology approaches

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CommCare used by a Community Health Worker

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Definitions – for today at least
 mHealth
Any technology or tool that relies upon tablets or phones
(i.e. Apps, SMS, USSD, and yes, phone calls)
May or may not integrate with other tools or systems
 Continuum of Care
“Continuum of care is a concept involving an integrated
system of care that guides and tracks patient over time
through a comprehensive array of health services spanning
all levels of intensity of care.” (Evashwick, 1989)
We think in terms of a continuum in terms of:
• different parts of the health system (ex: community and clinic)
• different health issues affecting a person

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Continuum of Care
De Graft-Johnson, Joseph et al. Opportunities for
Africa’s Newborns
http://www.who.int/pmnch/media/publications/
oanfullreport.pdf

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THE MHEALTH TOOLKIT

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mHealth Tools
•Works for low literacy, low cost to end users
•High cost and tech difficulty, limited data collection
•Twilio, Voto Mobile, CommCare
•BCC using client-focused health messages via IVR
Voice/IVR
•Low cost to end users, works on any phone
•Higher cost for data collection, limited data & “richness”
•RapidPro, RapidSMS, FrontlineSMS, CommCare
•Ex. TB program using SMS for receiving lab results linked to
mobile apps for service providers
SMS
•Richer experience (audio, media), lots of data collection
•High cost, doesn’t work on all phone (less suited for end clients)
•ODK, Magpi, CommCare, etc.
•Apps for CHWs and clinics, etc.
Mobile
Apps

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Limitations of some mHealth Systems
 Data Silos
Mobile-based data collection at one level but another system at
another
Smaller pilot area -> not worth integrating with other systems
 Limited focus
Typically focus on one program area or problem
CHWs do a lot and activities change over time (campaigns, etc.)
 Not Standardized
Tools may not follow the national standards exactly (or adapt
existing workflows)
 Technical Implementation
 Training users on a new tool
 Logistics of maintaining, supporting, distributing tool

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EXAMPLES

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Example 1: CoC Across Health System
 Example 1: Close the referral / counter-referral loop
Referrals are created at community level (danger signs, new
FP enrollments, etc.),
Referral info is provided in a clinic app and sent to the
mobile app for final close
App usage is needed on both sides. Is paper more effective?
 Example 2: TB Patient Tracking
Potential TB patients registered at a clinic using a web-
based application
Labs use SMS to report lab results back to clinics
TB adherence monitored using mobile tools
SMS or voice outreach to TB patients

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Example 2: CoC Across a Person’s Life
 Level 0: Basic data surveys for a person (no tracking of
data between visits). Replace basic paper tools
 Level 1: Basic longitudinal data – track a person’s
progress in a given program (ex. pregnancy or family
planning)
 Level 2: Comprehensive tracking a person over time
(household surveys, linking TB, pregnancy, HIV, etc.
programs to the same person)
 Level 3: Linking of patient data at mobile level to other
HIS tools

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Example 3: Integration of systems
 MCTS in India
Main national government used for tracking pregnancies
Non-government mobile based applications used for
registering and following up with pregnancies
Integrate two data sources
• Data conflicts? – nurses (ANM) responsible for dealing with
conflicts
• “Trust” layers – national system doesn’t accept direct input.
Needs approval from ANM
Do manual data entry on either end -> current solution
• Prone to error, and duplication of data, but easier than a
complex data integration workflow.

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Some Principles
 Start small but plan big
Focus your system initially (solve some key problem) but
don’t do it in a way that will stop you from expanding
SMS-based logistics limited to few products
 Design flexible systems
People change providers or move across catchment areas.
Sometimes parts of a system just aren’t used (ex. referrals)
and need to be tolerant
 Distinguish between data aggregation and
interoperability
Technical challenges (APIs?), each system evolves on its
own, different “views” of the world (are facilities the same
in each, do each have the same set of patients and IDs)

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BREAKOUT SESSION

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Exercise Guidelines
 Background on a situation
 Divide into groups of ~6 people
 5-10 minutes to discuss, 5 minutes to report back

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Discussion Question 1
 You want to improve loss to follow up from CHWs to the
clinic and there are a few ways to address this. Possible
solutions:
Provide SMS reminders and messaging to patients to remind
them to go to clinics
Develop a mobile tool at the clinic to help them view
incoming referrals
Update the CHW’s mobile tool to provide reminders to the
CHW to have them check-in on referred clients
Improve effectiveness of existing paper-based referral
system

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Discussion Question 2
 You want to improve the ability of the district to
aggregate and report their data. Potential solutions:
Build technology to directly feed CHW data to a national
health system
Provide basic web-based or email reports to clinics to allow
them to view data on their CHWs, and they can then
provide it to districts in the required format
Improve and update the existing paper based workflow that
CHWs, districts, and clinics are using

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Discussion Question 3
 Both clinic and CHWs are registering and tracking
patients. You want to make sure that patients are
receiving care correctly from both areas of the health
system. Potential Solutions:
Develop one larger system that integrates clinic and CHWs
data, sharing the registration data
Make a common user group phone system to help clinics and
CHWs coordinate patients
Allow both systems to work independently but have ways to
allow CHW to enter what has happened at the clinic
level. Manual reconciliation will occur at data aggregation
time (someone’s job).

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Discussion Question 4
 One common challenge for mHealth programs is that
they focus on only one area of the health system (ex.
malaria). Discuss the pros, con and concerns with the
two options listed:
Focus on a single health area but improve how well it
functions (adding supervision tools, improving counselling
content, SMS reminders to clients)
Expand to additional health areas (add additional modules
to an existing app, move from SMS to a full mobile app) but
less ability to really improve and focus on that one area.

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Guidelines
 Divide into groups of ~10 people
Each group should get a couple of handouts
 Scenario Overview

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Breakout Session Report Out
 Report back your group’s discussion:
1. Which area(s) did you choose to focus on (and why)?
• Ex: loss to follow up, expanding the health areas of the
mobile tool, improving the data and reporting flows, etc.
2. How did you decide to address this area?
• Ex: which tools, how fast, which levels, which health areas,
etc.
3. Describe at least 3 challenges to your proposal being
successful

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REPORT OUT & WRAP UP

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Thank you!
Contact us with Questions:
Sheel Shah sshah@dimagi.com
Michael O’Donnell modonnell@dimagi.com
Jeremy Wacksman jwacksman@dimagi.com
Additional Resources:
http://groups.google.com/group/ict4chw
http://www.commcarehq.org
http://www.dimagi.com

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Dimagi Global Head-office
585 Massachusetts Ave
Cambridge, MA 02139 USA
T: +1.617.649.2214
F: +1.617.274.8393
For more Information
E: information@dimagi.com
W: www.dimagi.com
W: www.commcarehq.org
W: www.dimagi.com/category/blog/