Mobile OpenMRS pilot implementation for MDR-TB in Karachi, Pakistan

[Omar Ahmed]

Hello all,

I am Omar Ahmed and I work with Interactive Research and Development (IRD) based in Karachi, Pakistan. In this post I will introduce an OpenMRS mobile implementation that we piloted this September. OpenMRS is an opensource electronic medical record system and and we use it's MDR-TB module for our TB program. The TB program has many projects running under it. For the treatment of TB patients we follow the internationally recognised and followed method of Directly Observed Therapy. In DOT a trained treatment supporter administers the dose to a TB patient and watches the patient take it. This is then recorded everyday along with other very important information such as side effects, any noticeable changes in patient's contacts (immediate family such as parents, spouse, etc). This information is usually contained in forms that are attached to files that each of the treatment supporter's carry. This is submitted back to the treatment coordinators who have multiple treatment supporters under them. The main database of the patients information is OpenMRS.

In the mobile application's pilot implementation we provided 3 treatment supporters Nokia 2710NE cell phones with the OpenMRS mobile application pre-installed. The mobile implementation or mOpenMRS allows quick reporting and enables the providers to view the patient status on the browser window when they log into OpenMRS. The data from mOpenMRS is updated at the server database in realtime. Another advantage of mOpenMRS is monitoring the performance, regularity and punctuality of the treatment supporters as well since all this information can be easily judged by the uploaded forms' timestamp, regularity and data(patient took complete dose, partial or didn't take at all). Another significant advantage is that any side effect during the treatment is quickly reported since in some cases a quick response is imperative for the patient's welfare.

The mobile application allows treatment supporters to download cohorts (group of patients assigned to each treatment supporter), download forms and upload filled forms to the server. The data is exchanged with the server is done via xforms (Wikipedia: Xforms) using the Xforms module of OpenMRS built by Daniel Kaiwa of Mackerere University, Uganda. The communication is done through HTTP and Bluetooth is also supported. The application authenticates users with the server. Each user can only view their own set of patients and filled forms. If a user logs out and a different user logs in, then he is not able to see the previous user's patients and data because it is removed. For use cases where a treatment supporter is in an area with low network coverage or has no credit, forms can be filled and uploaded later when the GPRS service up again.

For future work, we intend to incorporate GPS question type in the forms that are filled by treatment supporters so that the patient data can be mapped in a spatial database and also verify that the treatment supporters are filling forms inside the patient's house. This is a work in progress.

The application has been demo'ed at various sites including the WHO South East Asian Region's MDR-TB Recording and Reporting workshop in Nepal where our work was well received. I have attached a JAR file of the mobile application that can be installed on the phone. The demo account's credentials are:

username: jack

password: jack1234 

Feel free to use the application. A good set of actions to try would be:

Step 1: Download Data

1.Select Download Cohorts. You will be prompted for connection type on the first time download. Select HTTPS. Leave the URLs as they are because they point to the demo server. Select OK Select Yes for the prompt 'Allow Network Coverage' when the cohorts start to download.

2.You should see a notification 1 Cohort(s) downloaded

3.Select Download Patients. Select cohort name('jack' in this case and click Ok or Yes for the prompt that follows

4.Select Download Forms

5.You should see Forms downloaded alert.

Step 2: Fill Forms for a Patient

1.Go to search Patient.

2.For seeing all patients of the cohort 'jack', do not enter any thing and press OK (Note: you can search by name and/or patient ID as well for a specific patient(s) )

3.Select a Patient.

4.Click on any field of the patient data> You will see forms available for filling

5.Select MDR-TB DOT form

6.Start filling the fields.

7.When done, click Options>Save. Form Saved alert should be seen.

Step 3: Upload Data

1.Go back to main menu

2.Select Upload Data. Select OK or Yes for any prompts that follow

3.You should see a prompt, data uploaded successfully.

Please feel free to ask questions regarding this post and don't forget to give us your valuable feedback :)

Regards 

Omar Ahmed
Engineer,
 
Interactive Research and Development (IRD)
Suite 508, Ibrahim Trade Tower
Main Shahrah-e-Faisal
T: +92(21) 34327697
W: www.irdresearch.org

[neal lesh]

Dear Omar and the IRD team,

 

Thanks for introducing us to your important work with MDR-TB!   It’s really interesting to think about how a mobile application for treatment supporters can be used to extend the OpenMRS MDR-TB module (which if I understand correctly, was not originally designed for use by mobiles).   As usual, I have a few questions—but no need to answer them all.

 

I’m curious to hear more about the treatment supporters in your program.  Roughly how many patients does each support?   Are they paid? Do they work on a continual basis, always getting new clients?  

 

Is this program just for MDR-TB or are you considering the use of mOpenMRS for other TB patients also?   I wonder if the cost becomes much harder to justify for general TB.

 

Can you report on what you learned in your pilot so far?  Any surprises? 

 

Do you hope to go paperless or will the treatment supporters still maintain their paper files? Do you have specific thoughts on how the treatment coordinators will use activity data for the supporters that you mention below?  Enabling better supervision seems a common theme along the projects discussed here, so it would be great to hear any details you can offer.

 

And finally, I’m curious if you all have thoughts about how this work fits in with other ideas for monitoring TB-adherence such as smart pill boxes, taking pictures of people as they take their medicine, or X out TB.  Would it make sense to combine them with mOpenMRS or is this best seen as an alternative approach?

 

thanks much!

neal

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[stephen.lorenz]

Hello Omar,

Thank you for sharing with us your experiences with using mobile
technology to assist in the treatment of MDR-TB. I would like to
learn more about mOpenMRS. I am aware of OpenMRS-JR, built on top of
JavaRosa. Are these projects related to one another? How can I find
out more about mOpenMRS and where it is being developed and by whom?

Thank you,
Stephen

> done via xforms (Wikipedia: Xforms <http://en.wikipedia.org/wiki/XForms>)

> using the Xforms module of OpenMRS built by Daniel Kaiwa of Mackerere
> University, Uganda. The communication is done through HTTP and Bluetooth is
> also supported. The application authenticates users with the server. Each
> user can only view their own set of patients and filled forms. If a user
> logs out and a different user logs in, then he is not able to see the
> previous user's patients and data because it is removed. For use cases where
> a treatment supporter is in an area with low network coverage or has no
> credit, forms can be filled and uploaded later when the GPRS service up
> again.
> For future work, we intend to incorporate GPS question type in the forms
> that are filled by treatment supporters so that the patient data can be
> mapped in a spatial database and also verify that the treatment supporters
> are filling forms inside the patient's house. This is a work in progress.
> The application has been demo'ed at various sites including the WHO South
> East Asian Region's MDR-TB Recording and Reporting workshop in Nepal where
> our work was well received. I have attached a JAR file of the mobile
> application that can be installed on the phone. The demo account's
> credentials are:

> *
> *
> *username: jack*
> *password: jack1234 *

>
> Feel free to use the application. A good set of actions to try would be:

> *
> *
> *Step 1: Download Data*

> 1.Select Download Cohorts. You will be prompted for connection type on the
> first time download. Select HTTPS. Leave the URLs as they are because they
> point to the demo server. Select OK Select Yes for the prompt 'Allow Network
> Coverage' when the cohorts start to download.
> 2.You should see a notification 1 Cohort(s) downloaded
> 3.Select Download Patients. Select cohort name('jack' in this case and click
> Ok or Yes for the prompt that follows
> 4.Select Download Forms
> 5.You should see Forms downloaded alert.

> *Step 2: Fill Forms for a Patient*

> 1.Go to search Patient.
> 2.For seeing all patients of the cohort 'jack', do not enter any thing and
> press OK (Note: you can search by name and/or patient ID as well for a
> specific patient(s) )
> 3.Select a Patient.
> 4.Click on any field of the patient data> You will see forms available for
> filling
> 5.Select MDR-TB DOT form
> 6.Start filling the fields.
> 7.When done, click Options>Save. Form Saved alert should be seen.

> *Step 3: Upload Data*

> 1.Go back to main menu
> 2.Select Upload Data. Select OK or Yes for any prompts that follow
> 3.You should see a prompt, data uploaded successfully.
>
> Please feel free to ask questions regarding this post and don't forget to
> give us your valuable feedback :)
> Regards
> Omar Ahmed
> Engineer,
>
> Interactive Research and Development (IRD)
> Suite 508, Ibrahim Trade Tower
> Main Shahrah-e-Faisal
> T: +92(21) 34327697
> W:www.irdresearch.org
>

>  openmrs-midlet-1.6.jar
> 169KViewDownload

[Alvin Marcelo]

Thanks for this Omar. Great work! I just have two of my own:

1. are you using short codes?

2. are you using reverse billing?

alvin

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OpenMRS 1.6
OpenERP 5.0.12 (Medical 0.0.51)

[Sarah Bird]

Hi!

I work with Omar at IRD

@Neil - Most of your questions are program related so it'll take us a little while to find out some of the answers. Some things that I think are true, that Omar will have to confirm. Treatment supporters have a few patients, I think the max is 5-8 - being a treatment supporter for MDR-TB is time intensive. I'm not sure whether they're paid or not.  If they're not paid they will be incentivized through food baskets similar to what our patients receive. They don't work on "getting new clients" no.  They are not traditional community health workers and are not trained for case finding or anything like that. They are a nominated treatment supporter to help the patient through the 2 year regime. As Omar mentioned they would be looking out for symptoms within contacts.

We're focused on MDR-TB at the moment although the Indus Hospital (where the MDRTB program runs) also has a regular TB program.  MDR is a massively unaddressed problem in Pakistan - we already see a few XDR patients - so there's an urgent need for scale-up and support on this v. dangerous and difficult to treat disease.

Omar will be able to comment on lessons learnt - he's been running the program from a technical stand point. As far as I can tell it's going quite well.

Paperless for this kind of activity seems like it would be a goal.  The TB program itself has many paper-based reporting requirements for the national government etc. But, as you said, this is a management problem.  If we're going to scale-up effectively, I believe this system is not much better than paper if we don't use intelligent flagging and reporting to trigger alerts to supervisors & co-ordinators. So I hope that these are the kind of things that will happen moving forward.  2011 is going to be a v. busy year for our TB program - so we'll keep you updated.

Regarding adherence, as you may know, we are part of the team developing XoutTB. The group in MIT is working on the strips and we are both developing the software - for reminders, verification & incentive delivery - as well as our program team doing a randomized control trial to study the effectiveness.  This is the only other adherence work we're currently involved, but there's no particular reason for this.  I think it's important to highlight the difference between what we're doing on mOpenMRS and XoutTB.  The mobile application discussed here has come out of an immediate programmatic need; whereas the XoutTB system is still research at the moment.  If the XoutTB system proves effective then it may well become part of programs, but it is still in testing.  XoutTB and Smart Pill boxes aim to replace DOTS (and hence reduce costs and enhance scale-up opportunities); this application is designed to support DOTS in its current form.  The two are not mutually exclusive as you'll never completely eliminate treatment supporters, so there's no reason why the two can't work together.

I think the important thing is that good technology doesn't make a bad program better, but it can make a good program more efficient.  So for now, with mOpenMRS, we're just trying to help our TB program team get better access to data faster, while we continue to work on researching new alternatives.

@Stepen - OpenMRS-JR was a demo app built by the awesome team at Cell-Life - it's just a prototype for demo purposes to show that the javaROSA library can be used to build an app that connects to openMRS.  When I last spoke to them about it in Cape Town in September it wasn't a functioning tool and I don't think they were developing it further - this might have changed. If you've seen a working implementation I'd love to know.

When we came to actually implement an openMRS mobile system, we couldn't find any J2ME apps that were actually being used in the field.

Because there had already been work with the xForms module and the openXdata mobile client we decided to take this and build on it for our pilot. We also like the fact that the openXdata client supports lower end phones. However, as we are using 2710NE's in this case it's a null point.

We actually work closely with the Cell Life team on openXdata, but these projects aren't related.

mOpenMRS was developed by Omar and the informatics team at Interactive Research & Development who are based in Karachi, Pakistan. We're an independent non-profit who do both pubic health research and community outreach & treatment. Our website is really, really bad at the moment (we're working on it) but we do have a few videos posted at youtube.com/irdresearch. Our informatics group exists mostly to develop tools and support the needs of the many different projects we run (both research & service).  MDRTB treatment has been a big part of our program team's focus lately and this is where the request for this software came from.  We have a couple of hundred MDR-TB patients on treatment at the moment, and we want to improve our treatment management tools before we continue to scale this number.

@Alvin - the connection is made over GPRS not SMS so no short codes necessary. We give the field workers phones so we just pay the bill ourselves.

Sincerely,

Sarah Bird