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Phoning in Better Remote Medical Care

By Micky Baca

Phoning in Better Remote Medical Care
Photograph by Ryan Banez, MD

Students create cellphone system for developing nations

For millions of people in the world today, accessing medical care means walking for three days to reach a doctor or clinic. Even if they can make the trek, many can only afford such care "if they don't eat for three days," notes MIT lecturer Jhonatan Rotberg.

A cellphone-based clinical information system created by a group of Massachusetts Institute of Technology and Harvard University students could help change that, however. It's called Mocashort for "mobile care"and it uses a smart, Android-based phone to create an end-to-end remote medical diagnostic platform for healthcare workers in developing nations. Android is an open-source operating system for mobile devices initially developed by Google.

Moca leverages the fact that 80 to 90 percent of the world's population lives within range of a cellphone tower. It uses cellphones and an open-source software platform to link remote locations to medical professionals via a web-accessible, centralized health record system.

The ability to link careworkers in remote areas to trained medical professionals addresses one of the largest health problems the developing world facesthe lack of trained physicians, explains Dr. Leo Anthony Celi, research fellow in Medical Informatics, Harvard-MIT Health Sciences and Technology, and co-developer of Moca. While there is no shortage of untrained or semi-trained health workers in many of these countries, many are unable to provide needed medical care due to lack of expertise.

Oftentimes, it takes days for remote clinics to send information to the nearest physician and receive a diagnosis and advice on treatment, Celi says. By that time, it is often difficult to reconnect with the patient in need of treatment.

Moca provides a reliable way for such careworkers to transmit written information, photographs, audio, video, and even x-rays and ultrasound images when available to diagnosticians for immediate analysis. Careworkers use a simple set of options on the keypad, which can be customized for their needs. Moca then sends patient information to a centralized server with sophisticated workflow management and diagnosis software.

Procedures and attachments are uploaded via the wireless communication service General Packet Radio Service (GPRS) or WiFi to a Java-developed Linux server application called the Moca Dispatch Server.

Moca was built to be integrated with OpenMRS, a standardized medical records data base and archiving system that many developing countries use. The server handles packetization and synchronized functions and sends the data to OpenMRS, where diagnosing physicians access it via the web.

The immediate diagnosis that Moca can provide can make a profound difference for semi-skilled medical care providers in remote areas, Celi says. Suppose, for example, an elderly man comes into a remote clinic having difficulty breathing. Without Moca, it could take days for that facility to determine if he is suffering from tuberculosis, pneumonia, a lung infection, or a complication from heart failure.

An ongoing student project

Moca is the product of NextLab, an MIT course created by Rotberg and three other research scientists (Drs. Gari Clifford, Rich Fletcher, and Luis Sarmenta). It stems from a social network Rotberg founded called the Next Billion Network, which seeks to design innovative mobile technologies that help people in developing nations improve their lives.

Rotberg, a native of Mexico and a veteran IT entrepreneur, says, "There's always been a question in my mind as to what leaps forward you can do with a technology that so revolutionized the developed world. My question is, 'what can you do for the next billion people who are not impacted by it yet?'"

Celi and MIT doctoral student Andres Monroy-Hernandez came up with the Moca concept as their NextLab project for spring 2008 under the guidance of Clifford, Sarmenta, and Dan Myung from Dimagi, a software consultancy focused on using technology to help the developing world. Celi, who is an internist, an intensive care unit doctor, and an infectious disease specialist, is now advising subsequent classes of NextLab students who are continuing to refine Moca.

Celi acknowledges that mobile technologies have been used before for remote medical diagnosis. He singles out Moca's collaborative and open-source approach to providing such care as its most groundbreaking feature.

"To me, the advantage of this is that it's really able to harness the experts, not just from MIT, but also from Harvard," he says. The Moca team is also collaborating with other groups around the world to improve remote medical care.

Cost vs. innovation

Celi notes that Moca uses the more expensive Android-based cellphone because it is based on a multi-tasking, open-source platform that provides several technological innovations over previous efforts to use cheaper cellphones for remote diagnostics.

One important capability is packetization, which means that large image files are chopped up into smaller packets for transmission. This solves a problem discovered when less expensive cellphones were used in a remote diagnostic effort in Zambia. Since wireless networks in Zambia and other developing nations tend to be slow and have a high rate of dropped calls, image transmissions were often interrupted. Without packetization, large files had to be retransmitted in their entirety after such interruptions, leading to delays in care.

The Android phone allows careworkers to perform other functions to serve patients while files are being transmitted. It also provides an open-source platform that allows organizations, universities, and companies to contribute by making improvements to the system.

Celi hopes that less expensive Android phones will be developed soon to make the Moca system more affordable. Joaquin Blaya, a researcher at the Harvard Medical School-affiliated nonprofit Partners in Health, which seeks to improve healthcare in poor countries, says lowering the cost is key to getting Moca to sites where it's most needed. Moca's ability to transmit much more information than other remote diagnosis systems holds great potential in areas that lack clinics or Internet access, he says.

Moca is being piloted this summer in Batanes, the northern-most region of the Philippines, Celi's native country. Three NextLab students will test how well Moca transports x-rays from the island to Manila for interpretation.

Alvin Marcelo, director of the University of Philippines National Telehealth Center, is excited about Moca's potential to improve healthcare delivery. He hopes it will help offset the exodus of doctors from his country. "As we lose doctors to greener pastures, we have in Moca a way of getting them back again, albeit virtually," he says.

If this initial deployment is successful, the Moca team will conduct expanded tests in the region in conjunction with the Centers for eHealth and Telemedicine in Southeast Asia (CETSEA). Target countries are Vietnam, Laos, Cambodia, Indonesia, and Malaysia. The team also is slated to conduct a pilot in Mexico focused on prenatal care.

Challenges aren't technical

Healthcare experts are confident that Moca will work on a technical level. It's the other facets of bringing such a system to developing countries that they predict will be the most difficult.

Celi expects the biggest challenge will be implementing it in areas where medical care is currently paper-based. Clinicians will need to be trained to enter everything electronically. "It's the same problem we have here in the United States," he adds.

Partners in Health's Blaya says nurses in developing countries can certainly learn how to use Moca. He says the key to implementing it and any other telemedicine technology tool is figuring out what needs must be addressed locally and then training local people to maintain the system. Such efforts must also navigate the local political environment to gain acceptance, he says.

At the University of Philippines, Marcelo singles out cost as the primary hurdle. "I'm confident that all the best minds behind Moca can handle any technical challenge," he says, "But I'm concerned that not having an answer to who pays for the technology will be its Waterloo."

Celi says Moca will depend on its partner organizations to carry on Moca projects after the team pulls out. Governments and local non-government organizations are expected to provide funding for the system.

A healthier mobile future

Moca's ability to transmit ultrasound results will emerge as one of the most important improvement to remote medical care in the next five years, according to Celi. Ultrasound, currently limited to tertiary clinics, is an important tool for screening maternal and fetal health problems. It is also essential in diagnosing abdominal pain, which could stem from anything from food poisoning to kidney stones or gallbladder problems. Often, healthcare workers in remote areas automatically refer patients with such symptoms directly to a surgical center that's far away. "As soon as you refer a patient to a distant facility, half of them won't go until it is too late," Celi says.

Moca has the potential to provide remote careworkers with computerized diagnoses based on algorithms developed from the database. Celi adds, "We still don't have enough doctors, so we could have software available that would be able to come up with a diagnosis."

Rotberg says Moca has been the most successful project to come out of NextLab thus far. While it could be launched as a nonprofit venture at this point, Rotberg and Celi say it will remain part of a "student movement."

The reason, Celi explains, is that Moca will continue to benefit from a vital pipeline of ideas and innovations that students and other interested groups now provide. "We're getting this constant supply of ideas injected by very energetic and very bright students," he says.

If it is made a nonprofit with specific names attached to its achievements, Rotberg adds, "then others become uninspired to contribute. A student movement is so much more powerful. I think Moca will prove it."

Moca has also garnered attention from non-student public and private entities looking to collaborate on telemedicine innovations. Bernice Bower, director of Global Health Initiatives for the Honolulu-based Institute for Triple Helix Innovation, says the system has gotten "rave reviews" from healthcare experts. Institute members, from public health experts to medical anthropologists, praise Moca as a long overdue innovation, according to Bower.

Not only does the system allow for transmitting multiple types of media for remote diagnosis, she says, but it also provides for tailoring the language used in the system for cultural variations. "A lot of times, terms can be a barrier with indigenous healthcare workers," she says.

Moca also holds promise as a training tool for rural healthcare workers. Bower's group, which seeks to foster collaboration among academia, industry, and government on social issues including rural health, asked Moca to join its online network of healthcare professionals.

Her institute is watching the Moca deployment in the Philippines and wants to encourage more partnerships to help spread the technology.

Ultimately, Celi says, he would like to see Moca become the standard for remote medical diagnosis, able to interface with any other medical device to deliver mobile care. And he hopes it will help create the kind of patient-centered medical care network for resource-poor countries that those in the United States "take for granted."

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