Transcript Document

Technology supported Quality Control for
Superlative Results
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As it is said “Quality is never an accident, it is always the result of
high intension, sincere effort, intelligent direction and
skillful execution; it represents the wise choice of many
alternatives.”
- William A. Foster.
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Main Issues Tackled: TB: the biggest health crisis in India
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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Electronic datasets are necessary
“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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Data is unreliable: Sensational News Item in Times of India
“…the data was
being fudged.”
– Ghulam Nabi Azad,
Union Health
Minister (Times of
India, Oct 31, 2011)
Evaluation by a TB consultant appointed by
the State Government found a default rate of
36%, nearly 6 times higher than reported.
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Solution- High quality monitoring with electronic tools and other
systems
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eCompliance
Quality Audit
Incentive payments
Statistical analysis
Future : Big data
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eCompliance
• Runs on commercially available, ‘off-the-shelf’ components
• An inexpensive android phone
• A commercially available inexpensive finger print reader
Android Tablet
Fingerprint Reader
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Workflow with eCompliance
Patients are registered by scanning
fingerprint
At every visit, patients scan finger, creating a
verifiable log of patients who were present
Benefits
• Tracks missed doses, prevents default and halts the
Development of MDR-TB
• Accurate & real-time reporting for transparent
supervision
• Eliminates human error
• Prevents Tampering
• Attendance logs quickly inform health workers of
patients who still need to take the dose
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Features of eCompliance
• Color coding shows that a patient has been successfully
logged in
• The simple interface uses a minimal amount of text/ Text
free system
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Monitoring : Reports generated on eCompliance
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eCompliance Web: Web-based reporting system at the back-end
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eCompliance Web: Web-based reporting system at the back-end
Providers can quickly identify which patients have
• Missed their dose
• So they can follow up, within 48 hours, provide dose, further
counsel and convince the patient to join the therapy again.
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Tracking of patients & providers through Google Maps: Geo
Tagging
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Electronic attendance system
• Attendance of the field staff helps in keeping a check on the availability
of the staff on field and center.
• This creates indisputable evidence of the patient interaction, initial
house visit and follow-up of each missed dose.
• No chances of Human error.
• Auditor’s log details.
• Program Manager’s log details.
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1st Technology Application: eCompliance Text Free System
•The system has a Graphic User Interface (GUI) in which every
function is depicted using unique images.
• The system was first implemented in Dharavi in Mumbai on 1st
November 2013, using 10 terminals. We have registered 146
patients up to date.
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2nd Technology Application: Contact Tracing
• No health worker will ever miss any contact of an existing TB patient.
Once the symptomatic is identified, none of them will ever be lost and
everyone will be tested and ultimately enrolled in TB treatment if need
be. So the loss at various stages of the follow-up is totally eliminated
and detection rate is enhanced.
• This is how the quality of work and data management is being improved.
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3rd Technology Application: Lab Alert System
• The enrollment is faster and quicker, thus reducing the chances of
spreading infection in the community.
• There is no loss to follow up. Everyone who tests positive is put on
treatment.
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4th Technology Application: Electronic Receipt System
• The receipts of different financial products are generated on
eCompliance to stop fudging of the records.
• This keeps a check on the amounts collected from people for providing
them financial products and stops the mismanagement of funds as
everything is reported in real time, collected and deposited with the
Bank.
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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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Financial sustainability through increased productivity
• Automatic reporting increasing the efficiency of field and
office staff.
• Field cost: <30% (providers hired for 5 hours instead of 8
hours).
• Reduction in cost pays for hardware
• Increased accuracy and improved results is a bonus
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Important features of eCompliance
• Software can be easily modified or changed depending on the
requirement of the program.
• Off the shelf components: reduces initial as well as maintenance costs
drastically: Highly cost-effective.
• Easily replicable and scalable.
• Many reports can be generated automatically.
• Easy tracking of the staff.
• Built-in SMS reminders.
• Auditing being automated.
• More details.
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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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eCompliance: Implementation
Results
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Default <3%
Over 7,700 patients enrolled so far
Over 312,019 visits logged
Over 18333 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 Delhi since 2010
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Terminals installed in Takeo province in Cambodia
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Terminals installed in Bhiwandi, Jaipur and Mumbai centers in since 2012
Terminals installed in in M.P. (Bhopal, Gwalior, Gwalior Rural, Indore, Sagar), in Chhattisgarh
(Raipur, Korba, Durg-Bhilai) and Bhubaneshwar in Odisha
Total no. of terminals installed by the end of Dec 2013
Of which Android terminals were installed in South Delhi in Jul 2013 and in Mumbai in Oct 2013
Terminals installed in Uganda in 2012
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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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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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