Technology supported Quality Control for Superlative R esults

1. Technology supported Quality Control for Superlative Results

2. 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.

3. 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

4. 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

5. Data is unreliable: Sensational News Item in Times of India “…the data was being fudged.” • GhulamNabi 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.

6. Solution- High quality monitoring with electronic tools and other systems • eCompliance • Quality Audit • Incentive payments • Statistical analysis • Future : Big data

7. eCompliance • Runs on commercially available, ‘off-the-shelf’ components • An inexpensive android phone • A commercially available inexpensive finger print reader Android Tablet Fingerprint Reader

8. 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

9. 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

10. Monitoring : Reports generated on eCompliance

11. eCompliance Web: Web-based reporting system at the back-end

12. 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.

13. Tracking of patients & providers through Google Maps: Geo Tagging

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. Cost Effectiveness 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)

20. 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

21. 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.

22. 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

23. eCompliance: Implementation • Results • 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 23 Terminals used in Delhi since 2010 33 • 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 86 5 • Terminals installed in Takeo province in Cambodia 147 • Total no. of terminals installed by the end of Dec 2013 25 • Of which Android terminals were installed in South Delhi in Jul 2013 and in Mumbai in Oct 2013 3 • Terminals installed in Uganda in 2012

24. Immediate need: multilevel use of eCompliance This will incorporate All nationwide DOTS centers Microscopy centers Referral labs Public hospitals Drug sellers Quacks Pharma-companies Any individual/ organization that is involved in TB control Expected Benefits At all levels- ensure complete, comprehensive, real-time and transparent data Microscopy centers- will send alerts to CHWs, public hospitals to prevent “loss” after detection Public hospitals Referral labs Drug sellers - incorporate in DOTS to prevent misuse of drugs Incentivize patients ( for example a10 cents talk time for each dose taken or a regularly increasing incentive!)

25. Conclusion- the way ahead Develop eCompliance software further for • 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…