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G-Lab GHD 2008-10

What are the key issues, costs and benefits of point-of-care electronic data systems in low resource settings?
A case study using the example Baobab Health’s technology for ART clinics in Malawi

Reflecting on the value of data in health care delivery, Ellen Tompsett, one of four MIT Sloan students working in Malawi in 2009 on a Global Health Delivery Lab project, observes:

The staff average roughly 4 hours at a clinic with approximately 1500 patients.  If you can imagine a clinic with over 10,000 patients, the task seems quite daunting and much more time intensive.  It is easy to see how data irregularities can occur.  We were told by an MOH official that one 2006 audit (we were unable to locate a copy of it) showed a 10% difference between the numbers found by the MOH and those reported by the clinics.  In other words, there was a 10% difference in the numbers compiled by the clinic staff in preparation for supervision visits, and the numbers compiled by the supervision team.  In a country like Malawi that purchases $15M of ARVs per year, 10% amounts to a discrepancy of $1.5M.

The Global Health Delivery Lab is a graduate-level class at MIT that pairs teams of graduate students with partner enterprises delivering health care in resource-limited settings in Sub-Saharan Africa and elsewhere. Part of MIT Sloan’s flagship Action Learning program, the course puts students to work on practical challenges that limit access of health care, addressing specific business and organizational needs.

The following study, conducted by the four student team from MIT Sloan, analyzes the application of point‐of‐care (POC) healthcare technology in the developing world by comparing the point‐of‐care concept with both manual (non‐EDS systems) and back‐entry EDS. Point‐of‐care electronic data systems promise to improve the delivery of anti‐retroviral therapy in Malawi in many ways that back‐entry systems and paper processes cannot. The report examines the key issues point‐of‐care EDS addresses, and the costs and benefits of the technology using Baobab Health anti‐retroviral therapy system (BART) as an example. It begins with an overview of Malawi’s healthcare situation and proceeds to analyze the costs and benefits, deployment success factors, and other considerations associated with deployment point‐of‐care technologies.

The study highlights a number of issues that can be addressed by a point‐of‐care EDS:

  • Patient Management – Clinics face a burgeoning volume of paperwork associated with managing thousands of patient records, which are often missing or incomplete.
  • Quality of Care – Nurses make several complex calculations and decisions during each roughly four‐minute ART visit. These include staging, adherence, dosage, and body mass index determination.
  • Data Collection – The Malawi MOH conducts quarterly supervision visits to each ART clinic in the country. Data is collected manually, subjecting it to errors and inaccuracies.
  • Logistics and Planning – The MOH purchases $15 million worth of ARVs each year. There is a high human cost to understocking of drugs, and also measurable costs associated with overstocking, including transportation costs of redistributing drugs and disposal costs.

Download the full Case Study on PointofCare Electronic Data Systems for ART Clinics in Malawi (pdf).

Was this article useful to you? Please give us feedback on how to improve sharing our work by leaving us a comment or e-mailing us at ghd.projects.lab@mit.edu.

As global awareness of the HIV/AIDS epidemic has increased, so has funding to combat the problem
in the developing world. Assistance has poured in from sources such as the Global Fund and the
President’s Emergency Plan for AIDS Relief (PEPFAR). Such funding has enabled Malawi to
dramatically scale up its antiretroviral therapy (ART) program; yet, progress has not come without
challenges. The country’s monitoring and oversight policies have proven difficult to scale, as have
efforts to ensure consistent, quality care.
The following study was conducted by four students from the Massachusetts Institute of
Technology’s Sloan School of Management. It analyzes the application of point‐of‐care healthcare
technology in the developing world by comparing it with both manual (non‐electronic) data
systems and back‐entry electronic data systems (EDS). Using the Baobab Health Anti‐Retroviral
Therapy System (BART) is as an example, the report examines the key issues that point‐of‐care
systems address, and the applicable costs and benefits. It concludes that point‐of‐care systems
promise to improve the delivery of anti‐retroviral therapy in Malawi in many ways that back‐entry
and manual systems cannot.
The study highlights a number of issues that can be addressed by a point‐of‐care EDS:
• Patient Management – Clinics face a burgeoning volume of paperwork associated with
managing thousands of patient records, which are often missing or incomplete.
• Quality of Care – Nurses make several complex calculations and decisions during each
roughly four‐minute ART visit. These include staging, adherence, dosage, and body mass
index determination.
• Data Collection – The Malawi MOH conducts quarterly supervision visits to each ART clinic
in the country. Data is collected manually, subjecting it to errors and inaccuracies.
• Logistics and Planning – The MOH purchases $15 million worth of ARVs each year. There is
a high human cost to understocking of drugs, and also measurable costs associated with
overstocking, including transportation costs of redistributing drugs and disposal costs.
Acknowledging the problems identified above, in 2005, the MOH initiated a pilot program for EDS
in Malawi. Two firms participated: Baobab Health and Luke International Norway (LIN). Eight
sites are currently using the Baobab system, including 2 pilot sites. Baobab and LIN are working
with MOH to expand EDS use to sixty four sites over the next five years.
Baobab and LIN are in the process of determining the full cost of implementing EDS. This will
depend on the size of the clinics selected, as larger clinics will benefit from economies of scale,
lowering the total cost per patient. The MIT team believes that the costs incurred by clinics should
also be considered, since they contribute to Malawi’s total healthcare burden. For example, clinics
would greatly benefit from an on‐site resource that is equipped to perform basic maintenance and
troubleshooting (resetting the devices, ensuring all cables are connected, etc.). While training such
individuals would increase Baobab’s costs, it would also reduce the sites’ future support burden.
Such a policy could reduce retraining costs associated with clinical employee turnover.
Point‐of‐care electronic data systems promise to improve the delivery of anti‐retroviral therapy in
Malawi in many ways that back‐entry systems and paper processes cannot. Benefits can be realized
in data collection, logistics and planning, and clinical care. While benefits are achievable using a
back‐entry EDS, most are only made possible through the point‐of‐care approach. The MIT Sloan
team identified the following benefits of implementing point‐of‐care EDS:
ii
Data Collection
• Quarterly Supervision Visits – shift focus of supervision visits from data collection to
improving quality of care.
• Clinic Preparation for Quarterly Supervision Visits – increase the number of patient visits by
eliminating time spent compiling data for visit. Estimated additional patient visits to be
179,760 patients per year across all 214 clinics.
• Data Entry Center – eliminate the need for data entry center necessary for back‐entry EDS.
• Accuracy of Data Collected at Supervision Visits – improve accuracy of data by reducing
possibility of human error.
• Point‐of‐Care versus Back‐Entry EDS Data Accuracy – improve data accuracy, completeness
and timeliness by entering at the point‐of‐care.
Logistics and Planning
• Inventory Management Savings – allow for more effective forecasts and cost‐efficient
purchasing of drugs.
Quality of Care
• Patient Registration – faster registration, easy patient record look‐up.
• Patient Vitals – accurate, quick calculation of body mass index.
• Patient Staging – automatic staging allows for task shifting to less educated healthcare
workers.
• Laboratory Samples – improve sample management by reducing transcriptions and linking
lab results to patient digital profile.
• Clinical Process – standardize patient care and increase clinical decision support to allow
for task shifting to less educated healthcare workers. Track effectiveness of treatment
through easy access to patient records.
• Pill Count and Adherence Calculation – perform a more exact adherence calculation. Spend
less time on calculating adherence and more time focusing on the patient.
• Pharmacy Management – reduce error rate through automatic dosage and access to records
by pharmacists. Aggregate data helps prevent stock‐outs and overstocks.
• Scheduling and Appointment Management – optimize patient scheduling to smooth demand
for services and ensure more consistent utilization of employees.
• Missed Appointment Tracking – track no‐shows to help prevent emergence of resistance to
first‐line drug regimen.
• Vertical Integration of Patient Management – potential to integrate patient records across
the entire healthcare sector into other programs such as tuberculosis treatment, prevention
of mother‐to‐child transmission, and HIV testing and counseling.
• Staffing Management ‐ plan staffing levels in advance by tracking patient volume. Monitor
clinic staff by using software as performance management tool.
There are several factors that are needed to ensure a successful nationwide point‐of‐care EDS
deployment.
• Hardware Suited to Situation – use hardware built to last in hot, dusty environment with
limited or inconsistent power supply.
• User‐Oriented Software Development Process – involve the user in the development phase
to create a user‐friendly interface. Develop software using local talent.
• Systematic Training – conduct systematic training program for clinic staff and support, to
include provision of training documentation.
iii
• Dedicated Support and Maintenance Team – provide substantial ongoing support and
maintenance to current customers for a fee.
• Data Security and Back‐Up – ensure adequate onsite and offsite back‐up of patient data.
Point‐of‐care electronic data systems promise many benefits for health care in Malawi. At the same
time, there are several noteworthy cautions and caveats.
• Support – preventative maintenance and timely support are critical. Failure to provide
adequate and timely support can create the perception that the technology does not work,
which can have ramifications in future deployment plans.
• Transition – transitioning from paper to EDS will be gradual, given the learning curve and
prudent risk control policies. For processes where both EDS and paper are used, however,
duplication of efforts will at least temporarily slow care provision.
• Theft – loss of a Baobab terminal would not compromise patient data, although provisions
are made for a security closet. Server theft, however, could lead to significant data loss
and/or compromise.
• Scalability – centralized system would enable remote, real‐time data analysis, maintenance,
upgrades, and backups. It is possible that significant changes in architecture and/or
software platform would be required to construct such a system.
• Integration – Malawi is deploying two major point‐of‐care systems (LIN and Baobab).
Appropriate data standards will need to be developed and implemented if these systems are
to be linked.
As the volume of patients on ART increases, the Malawi MOH asserts it has no choice but to adopt
an EDS to manage the volume. By providing additional clinical decision support, a point‐of‐care
EDS is more than a data collection, monitoring and evaluation tool. As such, point‐of‐care electronic
data systems promise to improve the delivery of anti‐retroviral therapy in Malawi in many ways
that back‐entry systems and paper processes cannot. Malawi still has a long way to go in improving
healthcare delivery to all members of society. The care it has taken in managing the expansion of
its ART program gives us hope that this next step in digitalizing its operations will provide further
benefit to those under MOH care.

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