An overview of the tech

The WHO estimates that over 3.8 billion people lack access to essential medical care globally. In many areas of the developing world health facilities may be too far, too expensive, overburdened or may simply not exist. The doctor to population ratio in some developing countries is as low as 1:2000 and the least at 1:50000. Due to this historical lack of physicians, these countries have focused on capacity building of the frontline health worker to deliver certain components of primary care. Such innovations have generated enough evidence to prove the success of such health workers programs. This task-shifting from physicians to health workers has resulted in access to these components of primary care to the last mile. However, the health workers have been trained to provide services for specific services like maternal care, nutrition, family planning, besides others. There is a growing dual burden of disease necessitating a shift in the role of the health worker. With the doctor to population ratio predicted to fall even further and the rising incidence of non-communicable diseases, the access gap for essential services will only escalate and so it becomes all the more crucial to strengthen this ecosystem of health worker beyond their current scope. The last mile has suffered from a chronic health care access gap, it’s time to enable their basic right to evidence-based, ethical and dignified healthcare.

Intelehealth is an open source digital health platform to support frontline health workers to deliver primary care services at the last mile. It enables health workers to

• perform screening through systematic protocols

• gather high-quality clinical history

• conduct clinically-relevant physical exams

• perform point-of-care diagnostics

• facilitate teleconsultations with remote doctors for diagnosis and treatment

• provide preventative & curative health care services according to protocols

• track health improvement status

• refer patients to secondary and tertiary care services

• provide health education

(Planned future modules)

• connect with pharmacies for medication

• connect with laboratories for diagnostic tests

• connect with agencies for financial support

This platform is delivered through a combination of technology, training, and implementation support.

The Intelehealth platform consists of five main components:

1. Intelehealth Android Application

2. Intelehealth Web Application

3. Intelehealth backend (OpenMRS electronic health record system)

4. Ayu - a rules-based digital health assistant (previously known as HxGuide)

5. Data dashboards server

Open

1. Intelehealth Android application is a mobile software application developed in an Android platform which empowers FHWs (Frontline Health Workers) to provide primary health care access to the last mile.

Open

The mobile app uses intelligent data-gathering flowcharts so that FHWs gather comprehensive clinical history and conduct clinically relevant physical exams. The app independently guides the FHW’s through a series of questions and exams based on the patient’s presenting symptoms and medical history. Then through app FHW uploads, the gathered clinical data to Intelehealth Web Application (cloud server) which houses the patients Electronic Health Record (EHR). The app enables FHWs to download the data provided by a remote doctor and supports to explain the management plan to the patient which may include taking medicines, conducting additional diagnostic tests, or being referred to a secondary/tertiary facility. The Health worker also uses the platform to show patient education videos and perform counseling for common illnesses. Additionally, a health worker can forward the prescription to a nearby pharmacy or a test to a partner diagnostic lab to improve patient treatment compliance. If needed, the health worker provides information to patients about available government insurance or other microfinance schemes and assists them in the best way to access them. This greatly reduces the patient’s burden of navigating a complex and fractured health ecosystem.

Key features

• Easy and simple to use- designed for a low-literacy usage

• Works on low bandwidth mobile data connection

• Operates offline

• Customizable UI/ UX

• Language customization

• Patient registration

• Vital signs capture

• Job-aids for physical examination

• Capture Images such as profile images, physical examination

• Prescription printing and SMS feature

• A video library on patient education material

2. Intelehealth Web Application:

The intelehealth Web application doctor’s portal to view patients medical information and give appropriate diagnosis and treatment. The doctor portal can be accessed by using a web browser on a computer or mobile device.

The health worker forwards cases to a network of remote doctors for telemedicine-based diagnosis and case management. The doctor reviews the case in real time or asynchronously and provides a management plan. The doctor can view the patients visit summary such as vitals, complaints, patient medical history, physical examinations conducted by Health workers. With the help of patient data, the doctor prescribes diagnosis, tests to be performed and medical advises. The doctor may also speak with the patient and/or the health worker over a phone call for gathering more information, or for reinforcing the management plan. The doctor communicates with the HW and the patient using a shared decision-making approach to arrive at a management plan that is empathetic of the patient’s socio-economic condition. In areas where internet bandwidth is sufficient, the call might include video. Thus the platform can support both real-time as well as store-and-forward types of telemedicine.

Key features

• Clinical Case Management: Allows the doctor to give a diagnosis, write doctor notes, provide medications

• Medical Advise

• Follow up schedule

• Prescribe tests

• Patient Dashboard to give a quick summary of the patient’s past visits and vitals

3. Intelehealth backend (OpenMRS electronic health record system).

OpenMRS which is a collaborative open-source project to develop software to support the delivery of health care in developing countries. The application enables organizations to design customized medical records system with no programming knowledge (although medical and systems analysis knowledge is required). OpenMRS is based on the principle that information should be stored in a way which makes it easy to summarize and analyze, i.e., minimal use of free text and maximum use of coded information.

Once the health worker uploads the patient's information to doctors in an app, all the patient's are registered in the Intelehealth web application system using a unique identifier (OpenMRS ID). The patient's medical information such Patients medical records are available in OpenMRS.

The health worker tracks the patient’s compliance with the treatment through follow up visits and guides the patient through the continuum of care supported by an electronic health record system for longitudinal patient management (OpenMRS).

Key features

• Longitudinal Patient medical record management (EHR)

• Records patient history, family history

• Drug order entry module

• Authorized Access Only

• Data export in Excel for analysis

4. Ayu (a rules-based digital health assistant)

Ayu is a digital expert system to enable task-shifting of complex care processes such a history-taking, physical examination and disease management. Ayu (previously known as HxGuide) has over 20 protocols for preventative and curative care to support health workers to manage cases autonomously. When a case is beyond the level of training of a health worker they can start a teleconsultation with a remote doctor.

Ayu task shifts healthcare processes that are normally done by doctors or nurses to CHWs. Developed by clinicians at Johns Hopkins & All India Institute of Medical Sciences (AIIMS), it contains guided history taking flowcharts and clinical exams for 71 common complaints, 19 screening protocols, 104 physical examinations and a set of basic objective signs using diagnostic hardware that allows a health worker to manage care for a large majority of primary care conditions that are faced by rural patients. The Ayu protocols cover patient intake for presenting complaints about women’s health, maternal and child health, infectious diseases, non-communicable diseases, respiratory illnesses, neurological disorders, and mental health conditions. Ayu prompts the CHW to conduct 140+ simple physical exams like taking a picture of a rash, looking for swellings, measuring mid-upper arm circumference (MUAC), etc. The output is a concise medical history and physical examination note that serves as a starting point for the doctor to develop a management plan in further consultation with the CHW and the patient. This increases the quality of the consult, significantly reduces the time taken by the back end doctor, and has been shown to increase patient satisfaction.

Ayu also provides interactive job aids that help community-based providers during the physical exam, such as video, pictures, and sounds when relevant to the question being presented.

5. Data dashboards

Intelehealth dashboard is an information management tool that is used to track KPIs, metrics, and other key data points relevant to the organization. Through the use of data visualizations, dashboards simplify complex data sets to provide users with at a glance awareness of current performance.

At Intelehealth, we have implemented an open source “Apache Superset” BI tool to design dashboards. This empowers the users to use the past data to identify trends and use the information in a fruitful manner that can influence their future decision making. The effective use of dashboards will also help to,

• Get real-time data insights

• Ability to perform data analysis over a specific time period

• Identify areas that require urgent actions

• Take necessary actions to streamline workflows and utilize resources effectively

All these software platforms i.e Android app, Intelehealth web application, Intelehealth back end (OpenMRS), Ayu and the data dashboards work together to deliver comprehensive Health care services in the community. These software platforms along with Program implementation model have reduced the distance traveled and time and money to access basic health access. The Intelehealth software platform has benefited doctor from a greater convenience in being able to see patients virtually from their homes. They also spend lesser time per consult as compared to other models, since a preliminary clinical history and physical exam were already gathered by the CHW through Ayu. This improved efficiency in health consults results in a more scalable and sustainable telemedicine model. Overall the system delivers care using an approach that is cost-effective, scalable, replicable, has a greater impact and better ROI on healthcare spending.