E-Heza Point of Care Digital Health Record
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WHO & WHAT & WHERE
The Ihangane Project in Ruli, Rwanda needed to design new modules for E- Heza, point of care digital health record that supported frontline health workers to reduce maternal mortality rates and infant stunting through utilizing individual data.
Context
Location and Duration: Ruli, Rwanda for 8 Months
E-Heza is the first point of care digital health record in Rwanda and a functional web application. It is a collaboration between frontline health workers, the Rwanda Ministry of Health, and The Ihangane Project. It is currently being tested in 9 health centers in the Gakenke District with the goal of scaling nationwide. I was introduced with Ihangane Project through the Global Health Corps.
HOW ( I CONTRIBUTED )
I collaborated with nurses and members of the ministry of health to design news modules for the record, including registration, patient history, and antenatal. I managed 2 consultant firms to develop the product. And partnered with MOH to ensure that E-Heza protected the security and privacy of our patients.
The problem
High maternal mortality rates and stunting are critical problems in Rwanda. In addition to treating patients on a day to day basis, providers in remote, rural health centers are also responsible for gathering large data sets about their area to send to the Ministry of Health.
At the time, these providers only had access to a paper based system for both tasks. For infant patients, this meant that patterns about their health were easily missed and stunting would not always be treated in a timely manner. For the Ministry of Health this meant that reporting data had to be entered manually into the government database and reporting was slow, which hindered policy making.
We needed to equip providers with the ability to quickly analyze patient data in real time and identify patterns. This would give providers immediate insights, allowing them to be proactive with their treatment.
In addition to supporting in point of care needs, we also needed to reduce the effort and increase the speed at which we shared data with the Ministry of Health
Roles and responsibilities
I joined E-Heza as a Global Health Corp Fellow and Digital Health Specialist. My role was three pronged: I worked with nurses in rural health centers to design the tools they need to provide evidence based clinical care protocols, improve healthcare delivery, and utilize real time data to administer health education tailored for individual family needs.
I also was the product manager and analyst, managing work with our consultant organizations Greater Good Studios and GIZRA.
Lastly, I acted as a liaison between MOH, the E -Heza team, and our users so that we can implement a system that fulfills both frontline workers’ and government needs’, while protecting the security and privacy of our patients.
Discovery and research
After joining The Ihangane Project I familiarized myself with my new product and its context by reading about electronic health care systems in Rwanda, history of Rwanda’s health care and structure, policies and regulations, and the evolution of E-Heza. I also pickup up were previous TIP members left off, by completing the feature creation for nutritional modules. Using their research I to support the design and development gave me a crash course into E-Heza. The last part of my crash course was to shadow the healthcare works in health centers and members of my new team, many of whom were recruited directly from the health centers we with which we worked.
To prepare for the move beyond E-Heza’s MVP 1, my team and I met members of the Ministry of Health to identify what their priorities, needs, and concerns. Our founder determined based on the requests from the people we spoke with along with the official government program to reduce stunting in countrywide that we would tackle antenatal and registration modules next. The MVP of E-Heza tackled the first prong of MOH’s mission by collecting data on nutrition and infant health progression, but in order to ensure they had a good start after birth we needed to ensure the quality of their mother’s health.
After shadowing nurses in 6 of our 9 health centers, our hypothesis was that to ensure that the mothers were progressing positively in their pregnancy we had to identify correctly where she was in her trimester and if she was within the positive range for each antenatal activity to be done correlating to her specific stage.
But given mothers frequently did not travel to the capital to get an ultrasound it was difficult to be sure of her Estimated Gestational Age (EGA). If we could auto-calculate the EGA for nurses based on data they entered, we would ensure the likelihood of mothers being given the correct test for where they were in their trimester and ultimately ensure nurses will have the ability to look for the right pregnancy distress signs at the right time.
In order to identify the needs of nurses in during their antenatal work we conducted 1:1 interviews and I lead a participatory design workshop. We confirmed our understanding of their ANC process, identified their pain points, and co-created solutions.
Along with our key findings we learned that they struggled with prenatal nutrition, financial preparations, and getting mothers to the hospital on time to give birth. Mothers are encouraged to come into centers weeks in advance because ambulances are scarce and often don’t arrive on time.
Define
Our team and I created user flows based on our interviews and validated them with nurses. Then I created a product roadmap that I broke down into two phases. From the roadmap I began backlog of user stories to be ideated upon and developed.
In parallel our team utilized the mHealth Assessment and Planning for Scale (MAPS) Toolkit from the WHO. MAPS is a self assessment and planning guide designed to improve strategies for scaling and achieving long term sustainability. We divided the tasks in the toolkit and my focus was on identifying and defining our security and privacy needs. I researched global and Rwanda ehealth security policies, as well as met with a security expert to identify what steps TIP should take.
Lastly, the Head of Data and I met with experts in the domain to understand what other tasks we were not aware that we needed to accomplish as we grew and continued to the product. This included how to prepare our pilot locations, considerations for the tablets we were using, and experiments we could to do to validate our product.
Develop and ideate
I created lo and hi fidelity prototypes to test our ideas for the different tasks needed record data for patient history, antenatal tasks, and antenatal calculations including EGA and EDD. I also worked with our team to best deal with validations and how that would affect guiding the nurse during various levels of emergencies. We ran into issues when deciding how to standardize tasks, when they should be completed, and how often due to the fact that centers did them slightly differently. And the extent of tasks at each trimester were not the same as what our founder did in the US. This processes needed to be heavily tested. ( We also ran into interesting conundrums like - where in the process should you start a mother who came in for treatment who much much farther a long but had never seen a medical professional for her pregnancy before.
From our pilot we realized that the ability to register new patients would be a huge value add to nurses, who relied on our team to enter and remove patients. However when E-Heza had first been built there was a thread that forced a connection between a patient that was a mother to their child and vice versa. In order for us to register children without their mothers and mothers who did not yet have children we had to detangle this process. This coupling also caused issues with workflows, for example, you would have to get to the tasks for a child or to their record you would have to go through their mother’s profile. I create various iterations of flows to decouple the patients and the workflows.
Our solution
I worked with our consultant teams to help deliver the modules developed. Unfortunately I didn’t get to see them implemented before my fellowship was over. But I was able to see the pieces that I helped to complete when I first arrived to TIP piloted at Sorwathe Tea Factory schools.
My coworkers and I used E-Heza to gather nutritional and physical data from 300 children under the age of 5. We were able to see how features we were currently working on would help improve data collection, including making it easier to add newly enrolled children on the fly and removing children that graduated out of the program. Both of those tasks were extremely time consuming and had to be entered after the fact, potentially could have resulted in us having incorrect inputs.
I also developed a document to help measure whether or not new trained health workers can successfully use E-Heza as the product scale beyond the original health centers we worked with. Lastly, I created procedures to ensure locations were physically prepped and setup for the use of E-Heza in their facility.
Reflection
Although we were a small operation and were stretched thin we didn’t have specific numbers, other than those based on projections, to show E-Heza’s impact. Our priorities were directed elsewhere. I believe we should have conducted rapid experiments in order to validate our theories about the value E-Heza would provide not, only to ourselves but to members of the MOH, for example how much it would reduce the time to get data to MOH, increase nurses speed during consultations, and how providing automated calculations would better tailor the care nurses could provide to their patients.