emocha Boosting MDR-TB Linkage to Care in South Africa

This article was originally published on 13th January 2016 on www.ehealthnews.co.za

Since its implementation in a number of South African primary healthcare clinics in March 2015, a team of US and South African TB experts along with the technology experts at emocha have developed a platform that has revolutionised the linkage to care for multi-drug resistant tuberculosis (MDR-TB) patients (miLINC). During the 46th Union World Conference on Lung Health in Cape Town,eHealthNews sat down with the emocha team to find out what drives their platform and the impact it’s having on improving MDR-TB care in the country.

emocha’s miLINC for MDR-TB mHealth platform was designed after the NDoH approached Principal Johns Hopkins University Investigator at the MDR-TB Partnership South Africa, Jason Farley, PhD., to develop an mHealth solution that could improve  linkage to care to meet the national strategic plan of cutting it to less than five days.

“Having worked with the NDoH on a number of projects over the past decade, they approached me to initiate this MDR-TB linkage project,” said Farley. “Because emocha was developed at John Hopkins, I knew it would be the perfect solution.”

The emocha team consists of engineers and designers working side-by-side with scientists and clinicians to run this mHealth linkage programme, which aims to streamline continuous quality treatment to ensure that TB and MDR-TB patients are identified and linked to facilities where they can receive life saving therapies. The programme is funded by the MDR-TB Partnership, an initiative between the Johns Hopkins University School of Nursing, the National Department of Health (NDoH), JPS Africa, the National Health Lab Service (NHLS), the CDC and the Global Fund.

Farley went on to explain that the best way to offer decentralised care for MDR-TB patients is through mobile technology. “Mobile devices are used to capture patient data, and share that data across several providers. Our interface provides TB test results from the NHLS and improves direct patient linkage because we can rapidly identify a newly-diagnosed patient and communciate with them directly linking them to care,” said Farley.

Putting the power into the hands of the CHWs

The miLINC platform consists of three synchronised applications that guide patients from primary health clinics to treatment initiation at specialised MDR-TB clinics.

The first is the Primary Health Clinic App, which is used by nurses and/or community healthcare workers (CHWs) at the point of care to enroll suspected TB patients simultaneously during the collection of the sputum sample. The app collects critical identification information, including the national ID number, medical record number, phone number and address. The specimen barcode is also collected so that it can be linked to the NHLS results.

The second app, the Linkage Officer App, is intended for CHWs to check results that are matched from the NHLS against enrollment data from the clinic on emocha’s cloud-based secure server. Results are made available and visualised through coloured icons next to the patient’s name so that CHWs can identify who does and who doesn’t have MDR-TB, or who needs to be retested due to an insufficient sample, all at a glance. CHWs can then follow up with patients accordingly while also consulting the nurse initiator at the MDR clinic to make an appointment.

“Provided the patient registered a valid cell phone number, as soon the CHWs get results back from the NHLS an SMS is sent to the patient telling them to come back to the clinic for further care and treatment, or to return to the clinic so that they can repeat the test urgently as opposed to waiting for the patient to come back in a few months still coughing and still infecting their family,” said emocha’s local implementing partner, mHealth Implementation Director – MDR-TB at JPS Africa, Manivasagan Naicker.

The third app, the MDR-TB Clinic App, allows doctors and specialist nurses at the MDR-TB clinic to check the patient in and close the loop by initiating care guided by clinical decision support algorithms. The app also acts as an online diary system where every morning the doctor can log in and see their appointments for the day.

“In the background the emocha mHealth platform calculates the turnaround time from diagnosis of a patient to receiving the result to when the treatment is initiated. All of that information is captured on a dashboard that can be accessed online when the user logs in anywhere in the world,” said Naicker.

“Through the portal, District Managers can see in real time all the patients in their district who have been enrolled. It’s also coded in terms of stages, from stage one when the patient is enrolled to stage five when the treatment is complete,” continued Naicker.

Transforming TB care

The faster you link an MDR-TB patient to care the faster you put them on the correct treatment regiment, which results in faster prevention of the disease in both households and in the community.

“If we diagnose the patient in our primary healthcare clinic and we’ve suspected that they have TB, why do we need to bring them back to that clinic to give them the results when we are going to be sending them to another facility for treatment? This means they have to travel a long distance to come back and re-queue for up to four hours, in which time they could potentially infect other patients and healthcare workers,” said Farley.

“So if we can unpack that by getting the patient to the next clinic location where they’re actually going to get that treatment faster, then that also helps other patients and healthcare workers avoid exposure,” continued Farley.

With the miLINC system in place the time between TB diagnose to initiation of treatment has dropped significantly. “Not so long ago it took about 70 days to link someone to care, since then the rapid diagnostic technology has moved that down to eight or ten days, and we’re moving it down to less than three with our technology,” said Farley.

Making an mHealth system sustainable

Unfortunately, it’s common practice for organisations to visit a developing country and pilot their mHealth system and then leave again. emocha is different because their success depends on building relationships on the ground.

“A representative from emocha has visited South Africa seven times now in the last 18 months; we have a very active engagement with the users of our platform,” said Co-founder and Director of Marketing at emocha, Morad Elmi. “It’s essential to the implementation and roll out because if there’s no buy in from the clinics and there’s no one there to use it, or no one wants to use it, then it’s a waste of innovative technology and resources.”

The intended users of the miLINC system take part in a training programme developed by Johns Hopkins Center for Clinical Global Health Education and implemented by JPS Africa, which also helps to train, prepare and oversee the users. “The users tend to be very comfortable with the system and the different apps. We’ve had positive feedback that it’s helping to streamline their work because duplication is no longer an issue and they no longer have to decipher handwriting and worry about losing papers, etc.,” said Elmi.

“The system forces better data input because when the information is entered in you are also required to scan a bar code to validate the information. We’ve worked very hard to make it very simple,” continued Elmi.

Elmi added that through constant communication with and feedback from the ground users, every two weeks the miLINC system is improved and updated based on recommendations and requests.

emocha’s future role

The NDoH’s goal is to get TB and HIV integration on the Tier.Net data management system collectively. It’s therefore emocha’s goal to feed into that system. “Manivasagan is working to lead an initiative with our electronic data register for MDR-TB, the EDR, with Wham Tech, who are the developers of both drug sensitive and MDR-TB registers” said Farley.

In December 2015, miLINC rolled out in the Nelson Mandela Bay and Buffalo City Metropolitan districts, and will soon be followed by other districts in KwaZulu-Natal. “We’ve got a cascading plan to roll out across the country depending on buy in from each province and the completion of site readiness assessments to ensure there’s appropriate infrastructure. But by the end of our project we aim to have 52 districts on board,” concluded Naicker.