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Tackling Telemedicine Challenges

By Micky Baca

Promoting best healthcare practices
Sana members confer with World Health Organization (WHO) representatives. The two groups are pursuing a shared goal of bringing established best practices in maternal and child care into the hands of front-line community health workers in remote regions. Photograph by Richard Lu.
Group Finds It Takes More Than New Technology

June 17, 2010—A group of MIT and Harvard University students who created a cellphone-based platform to deliver better healthcare in developing countries is grappling with a whole new set of challenges in deploying the innovation in real-world settings.

Sana, recently renamed from Moca (short for Mobile Care) due to a conflict with another organization of the same name, uses smart, Android-based phones to create an end-to-end remote medical diagnostic platform aimed at remote healthcare providers. It leverages the fact that most of the world today lives within range of a cellphone tower. Sana allows remote healthcare providers to send written information, photographs, audio, video, x-rays, and, if available, ultrasounds to trained medical professionals for diagnosis via a central server.

Dr. Leo Anthony Celi, research fellow in Medical Informatics, Harvard-MIT Health Services and Technology, and co-developer of the Sana project, says that over the past two years his group has established that the technology will work. And, he admits, “We thought we would be deployed by now.” However, Sana has discovered that the biggest hurdle it faces isn’t technological: It is implementing such improvements in the face of logistical, political, cultural, and financial barriers.

“At MIT, we have innovations left and right and many projects get piloted,” Celi says. “But a lot of them don’t get beyond that.” Getting stakeholders to see the value of such technology and work together to use it is the critical element, he says. “If it means more work [for healthcare providers], forget it. It’s not going to work,” Celi adds. “We realize that technology has to be used to primarily support and strengthen the existing healthcare infrastructure.”

That’s why Sana is shifting its focus from technology development to forging implementation strategies to successfully deploy its system where it is needed. Among the changes, Celi says, is a broadening of the local team beyond the small group of mostly student developers who had previously spearheaded the Sana effort through a class called NextLab at the MIT in 2008.

Sana has connected with the Harvard School of Public Health and Harvard Business School, he says, to add business students interested in social entrepreneurship and public health students and doctors with different medical specialties to the Cambridge, Massachusetts team. Eight specialties and subspecialties are currently represented in the group.Post-doctoral medical informatics fellows from the various Harvard hospitals also have joined the team.

Sana is also establishing a formal partnership with the Harvard School of Public Health, which Celi says is increasingly interested in promoting the adoption of eHealth solutions in developing countries.

In turn, Sana is looking for its partner organizations in countries where it hopes to deploy its new technology to also assemble similarly broad teams.

Celi says Sana has discovered that relying on its local team to get its innovative system established in developing countries is not sufficient to get the program off the ground.

A course in collaboration

At the center of Sana’s new approach is course slated to be launched at MIT next spring on best practices in design, implementation, and evaluation of mobile health (mHealth) technology and other eHealth solutions. It will include instruction on how to work collaboratively on implementing mobile technologies. While the initial Sana mHealth Lab will be conducted locally, Celi says, Sana is working with universities in Mexico, India, and the Philippines to allow students from those locations to take part as the course gets established.

“One of the course’s main goals is cross-pollination,” Celi says. “We want students here to learn from those in partner organizations how to implement and scale telehealth initiatives.”

Eventually, the lecture materials will be made available to anyone who wants them around the world.

“Instead of just providing software, we want to actually teach how to design solutions and bring groups together,” Celi says. “For this to be successful, all the incentives have to be aligned. Technology is the easiest piece; it’s getting them to work together that’s most challenging.”

The course also will address issues such as educating healthcare providers in rural areas on the importance of documenting the care they provide. Many keep no records at all, Celi says

“We want students here to learn from those in partner organizations how to implement and scale telehealth initiatives.” —Dr. Leo Anthony Celi, research fellow in Medical Informatics, Harvard-MIT Health Services and Technology, and co-developer of the Sana project

Last February, Sana released the source code for its system, allowing healthcare providers around the world to use it as building blocks for customizing telemedicine systems to meet their needs. Celi says making Sana software open source is part of the collaborative approach needed to use technology to improve healthcare worldwide. As others use the software, they will also contribute to its improvement in the open-source tradition.

Over the summer, Sana will be conducting development workshops in India and the Philippines to help those using its software add functions to their systems.

Making funding inroads

Getting partners to invest, both financially and in committing to making healthcare delivery changes to sustain the new technology, is critical to successfully deploying Sana, Celi says.

Sana doesn’t want to rely on grants to pay for projects in developing countries because such funds tend to run out within a year or two. Organizations don’t tend to be committed to projects in which they have no stake, Celi says.

To that end, Sana is working to cultivate private, long-term funding sources and has made some progress. It is working to establish a relationship with E Health Point, a for-profit venture in India that operates clinics in remote villages and is interested in customizing Sana for its use, Celi says.

Meanwhile, Sana has won several grants that it will use to help fund its new MIT course and to hire a full-time developer to coordinate its operations. They include a $100,000 award from Vodafone Americas Foundation, $50,000 from the mHealth Alliance, and $33,000 from the India Innovation Fund for Building Partnerships for Mobile Based Healthcare Technology.

Sana is partnering with the mHealth Alliance and the World Health Organization (WHO) with the shared goals of bringing established best practices in maternal and child care into the hands of front-line community health workers (CHWs) and measuring adherence to these best practices. Decision tree algorithms are embedded in the Sana platform which will assist CHWs in evaluating, triaging, and treating patients.

For example, referring a high-risk pregnancy to an obstetrician may be standardized among CHWs using Sana by incorporating the criteria as defined by the WHO and automating the referral process. With Sana, the WHO and mHealth Alliance can now not only offer countries recommendations on various care delivery processes, but also a tool that will integrate these recommendations into the day-to-day workflow of CHWs. In addition, implementation of these recommendations is measured and tied with clinical outcomes tracking for quality improvement purposes.

Sana is also among the technologies featured in a Smithsonian exhibit at the Cooper-Hewitt National Design Museum in New York City entitled “National Design Triennial, Why Design Now?”

Sana is seeking to use cellphone technology to deliver better healthcare technology to remote clinics like this one in the Philippines.

Team members up for the challenge

Ted Chan, a recent MBA graduate of MIT’s Sloan School of Management, is a longstanding member of the Sana team focused on how to make it a sustainable business model. Technology alone, he says, “almost never gets you all the way” in launching a social improvement project. A technical concept works fine in the laboratory, he explains, but needs entrepreneurial thinking to overcome the issues in the real world. He is focused on social entrepreneurship—using business tools and technology to create social change.

Sana, Chan says, needs to scale beyond the tens of users with hundreds of patients who took part in pilot programs to thousands of users with millions of patients. That requires sophisticated workflow management strategies. “It takes a lot of energy, capital, and smart people,” Chan says. “It’s a mix of technology and coming up with buckets of funding. A business person can really have a lot of impact.”

In fact, Chan is planning to start a company that offers software to architect and deploy telehealth innovations on a wide-scale basis in the Philippines. He says he favors a for-profit model for social improvement efforts because the nonprofit approach creates dependency, requiring leaders to spend half of their time working to raise donations.

Sana’s open source code is helping the project move forward without shouldering hefty development costs, according to Chan. “Having people embrace it and tell you how to make it better is key,” he says. “If you were going to develop an end-to-end telehealth system from scratch, it would cost more than a million dollars.”

Jonathan Payne, Sana team member and a recent graduate of the Harvard School of Public Health with a master’s degree in health policy management, says it is Sana’s unique approach to improving world health that attracts him to the project. The group has achieved a sustained collaboration in its efforts to use mobile technology to improve rural healthcare, he says. And now Sana is striving to advance that agenda of collaboration to the public health community at large.

Sana’s approach of working with healthcare providers in rural areas to tailor its mobile care system to their needs and capabilities is another thing that sets it apart, in Payne’s view.

Succeeding in overcoming the many barriers to getting its technology deployed in remote regions of developing countries is going to be a tough job, Payne says. But the fact that the public health industry has, in recent years, decided it is worth pursuing the deployment of such technology in such regions is encouraging. And, he says, Sana’s decision to make it a priority to educate the global healthcare community on the value of working together will help promote best practices.

He adds that Sana is truly committed to promoting best practices in rural healthcare settings, even if those practices don’t include its technology.

Progress in the Philippines

University-based team is learning the ropes

More than half the population in the Philippines doesn’t have access to medical services due to the lack of doctors in rural areas. Jose Eugenio Quesada, an IT professor at Asia Pacific College (APC) in Makati City, thinks Sana can help fix that.

Quesada learned about the MIT-based Sana effort when team members Ted Chan and Katherine Kuan spoke about the project in Manila in July of 2009. He is now heading up a team—including APC students and graduates—that is studying using Sana in conjunction with OpenMRS, a standardized medical records data base with which Sana was built to integrate.

Quesada is working with the Sana team at MIT via the Internet to install and learn the different components of the cellphone-based platform. The goal, he says, is to customize a system that will allow doctors now concentrated in urban areas of his country to extend their reach to rural populations “that badly need their services.”

Currently, his team is focused on learning the technology fundamentals. It has installed the Sana dispatch server as well as OpenMRS and succeeded in sending a patient record from the phone to OpenMRS. The team will work with Sana members scheduled to visit the Philippines over the summer.

The effort Quesada manages is funded by CS Foundation Inc., a nonprofit organization that supports projects to help the Filipino people, as well as by APC. His group is currently completing an electronic medical record system that it built from scratch for the Noordhoff Craniofacial Foundation Philippines, Inc., a nonprofit organization that provides treatment to children with cleft lip/palate. Once the system is implemented, Quesada and his team will work with doctors to test and pilot the use of Sana.

While Quesada acknowledges the many hurdles his group faces in deploying Sana in his country, he says mastering the technical challenges is its current task. Beyond that, he says, his group plans to work with doctor organizations “to deal with the issues together.”

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