In our September Technology Salon, we took on James BonTempo's pertinent question of What Does the "m" in mHealth Really Mean? in a spirited debate with technology and development practitioners.

We were seeking a better definition of mHealth than the current focus on devices, and specifically the hype around mobile phones. As one participant bemoaned, it seems that every health project with a mobile phone or PDA, no matter their usage, is now an mHealth project.

(Want to attend the next Technology Salon? Then subscribe to our meeting announcements.)

Is this mHealthcare? (photo: Data Dyne)

So we sought to put parameters on what could be called an mHealth project, and through that, come up with a new definition for mHealth. After an hour of vibrant debate, we developed these four aspects for mHealth projects:

As we looked at the four requirements listed above, we realized there needed to be one more change to the concept of mHealth, and that's the limitation of the word "health". We're really talking about a holistic approach to improving health outcomes, with an end-to-end communications infrastructure, so we're really talking about mHealthcare, not mHealth.

Yet even mHelathcare is still a subset of the more holistic eHealthcare, where these field-focused solutions tie into national electronic healthcare systems that can empower changes in people and policy at the country level.

Back down at the Technology Salon level, we concluded with a simple hope for our discussion. That this exercise would help each of us better discuss and explain what the "m" in mHealth means in our respective professions and promote a more inclusive and pragmatic concept of mHealthcare to the larger development and technology communities.

In a recent Twitter exchange, James BonTempo asked a very pertinent question about the current mHealth buzz:

The only mHealth definition? (Img: DataDyne)

Should definition of #mHealth include devices (wondering specifically about netbooks) or simply the concept of mobility?

He followed up his initial query with a simple poll that asked if mHealth should include a list of specific platforms or just the concept of mobility. So far, Twitterers agree, the "m" in mHealth should represent mobility, regardless of form factor.

But that's different from the general notion of mHelth, represented by the mHealth Wikipedia entry, which focuses on equipment "mHealth is a recent term for medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, PDAs, and other wireless devices"

In our next Technology Salon, we'll explore what the "m" in mHealth means for those who actually practice mHelath, with these field-experienced experts:

• James BonTempo who says, "Ask someone about #mHealth they'll mention (smart)phones and PDAs. But who's counting users with laptops? After all, they are "mobile" devices."
• Josh Nesbit who says, "I tend to frame everything in reference to end users, so the "m" describes the mobility of healthcare workers, facilitated by devices."
• David Isaak who says, "I am definitely in the "m" in mHealth being everything mobile. I usually use the acronym "mICT" for a broader view."
• Wayan Vota who says, "Ask those in #mHealth hype and they say (smart)phones. Ask those who DO #mHealth and they talk about holistic ICT ecosystems."

But enough about what the four of us think. Come out Thursday morning to give your own voice to the conversation. Our goal: a shared definition of mHealth from an implementer's perspective, and a better understanding of mHealth for everyone involved.

What Does the "m" in mHealth Really Mean?
September Technology Salon
Thursday, September 10 8:30-10am
UN Foundation Conference Room
1800 Mass Avenue, NW, Suite 400
Washington, D.C. 20036 (map)

Do note that we'll have hot coffee and Krispe Kreme donuts to wake you up, but seating is limited and the UN Foundation is in a secure building. So the first fifteen (15) to RSVP will be confirmed attendance and then there will be a waitlist.

As I listened to Mike McKay, former country director of the Baobab Health Partnership, speak about how his organization is improving patient care with ICT in Malawi, I was struck by four key themes in Baobab's solution:

Mike McKay of Baobab Health

1. Start with Patient Data
2. Keep Technology Easy to Use & Modify
3. Always Build Local Capacity
4. Project Poverty is an Advantage

Now neither Mike, nor Baobab's founder, Gerry Douglas, made all these points explicitly, but they are the takeaways we can learn the most from.

Start with Patient Data

Knowing a patient's past medical history is critical to continuity of care, particularly for patients with chronic illness. Do you know if the patient in front of you has tuberculosis? Or HIV? Or both plus malaria? Or is on any other medications or has any peculiarities you should know about them before you diagnose or treat their current ailment? If you had their medical records, you may.

And if you could track vital signs like body weight and Mid-Upper Arm Circumference (MUAC) over time, you could map its fluctuations against the patient's ails. Aggregate that data from all patients, and you could track disease and malnutrition across entire populations.

This is the promise of starting with patient data. And capturing the data electronically, at the point where its taken - from initial registration to actual patient-clinician interaction - makes the input process more streamlined and the data more accurate and timely; the approach Baobab took to great success.

Even though Baobab initially started in the pediatric ward of Kamuzu Central Hospital in Lilongwe, by focusing on creating an easy way to record patient data, they've been able to expand into other medical wards, and other clinics, across the country. At the same time, they are able to deliver accurate and timely aggregate data to the Ministry of Health. Baobab has now issued nationally unique patient ID numbers to over 800,000 Malawians, and tracks more than 20,000 HIV patients using their point-of-care approach.

Keep Technology Easy to Use & Modify

Even in Lilongwe, the capital of Malawi, electrical power is intermittent. Yet, if you are using an electronic patient records system, you have to commit to 100% uptime during clinic hours. Technology solution needs to be very energy-efficient so it can be run off backup power as needed. Baobab has introduced a 48VDC approach taken from the telecommunications industry to provide multi-day power backup using locally available solar batteries. You are also working with a user population that is not usually familiar with computers, so your solution needs to be dead simple. In general, the technology used has to be both cheap to buy and cheap to ship to your clinical sites, and also cheap to maintain and customize.

Back in 2001in the hunt for a solution that could be robust yet easy to use and cheap, Baobab stumbled on the Netpliance I-Opener, a low-cost, low power solution for Internet access. This device, with some customization, seemed perfect for running electronic patient records software as a web-based application with a touchscreen interface.

The real innovation came with that touchscreen interface. By eliminating the keyboard and mouse, Baobab was able to make its patient record system easy to use by everyone - from doctor to janitor - eliminating the need for users to have advanced ICT skills. And by using Open Source software, they were able to develop their own solutions, and modify them as needed with local programmers making the changes.

The only drawback is the limited supply of their original touchscreen hardware - its not longer produced and current touchscreen hardware is over $700 per device, relatively expensive for Baobab's saturation model, but still considered to be a viable solution by Baobab.

Always Build Local Capacity

Let's be honest. Expatriates are expensive, often temperamental, and almost always temporary. So for any project to have real staying power, it needs to be designed for handover to local staff from the beginning. But at the same time, its usually hard to find local staff that have a Western work culture. Which means that projects also need to be constantly training local staff, grooming internal candidates for advancement.

Gerry and Mike were both committed to transferring their knowledge and skills to their local staff, often hiring fresh graduates to train them in Western methodologies - especially software development. In fact, once trained, their local programmers were able to get more and better feedback when Gerry and Mark were not involved in requirements definition (so called "mzungu free meetings"), as local clinical staff were more honest and open about software issues with their countrymen than the expatriates.

Baobab Health is now almost entirely locally staffed, only the Country Director is an expatriate, and that's more a function of her skills and leadership than a specific need for an expat.

Project Poverty is an Advantage

It may seem counter-intuitive, but being resource constrained can actually be beneficial to a project's long term success. When there is little money to be spent on extravagance, the organization is very focused on delivering quality on time and on budget. And when low budgets are expected to continue, the project can be designed to have low maintenance costs, making sustainability easier to achieve.

For Baobab Health, its tiny budget kept it lean and focused. It only recently reached $200,000 a year, so everything - salaries to software - was cost-efficient. Baobab was able to reject opportunities for mission creep and helped it achieve acceptance by the Ministry of Health. Its seen as a real Malawian solution, not a donor-driven external organization.

Now that Baobab is looking at scaling up, and has a significantly increased budget, the challenge will be for it to keep that lean, focused organization.

In last month's Technology Salon, we looked at Health Information Systems that improved reporting systems for governments. But what about improving patient care? Giving clinicians support and feedback at the point of care can bring about immediate changes in diagnosis and treatment, and start the reporting process with high-quality data.

Baobab Health Partnership is using innovations like touchscreen clinical workstations and unique power systems to guide low-skilled healthcare workers through the diagnosis and treatment of patients according to national protocols. They've even developed a HIV eVCT System - a locally designed and implemented solution to advance medical care in real time for Malawians in resource-poor settings.

Here is a video of their electronic records system in action registering new patients:

We'll have Mike McKay, former country director, lead us through their technology choices and into a larger discussion around improving feedback loops inside the clinic, not just above it. We'll also have a hardware show and tell to get acquainted with the technology.

Improving Patient Care with ICT: A Malawian Example
July Technology Salon
Thursday, July 23 8:30-10am
UN Foundation Conference Room
1800 Mass Avenue, NW, Suite 400
Washington, D.C. 20036 (map)

Do note that we'll have hot coffee and Krispe Kreme donuts to wake you up, but seating is limited and the UN Foundation is in a secure building. So the first fifteen (15) to RSVP will be confirmed attendance and then there will be a waitlist.

In this month's Technology Salon, National Health Information Systems: Who Uses What, Where?, we discussed a recently-completed study by Vital Wave Consulting that surveyed the global landscape of national HIS ecosystems in the developing world. The overall outcome may surprise some development practitioners, but its well known to IT experts: basic change management matters more than fancy technology.

(Want to attend the next Technology Salon? Then subscribe to our meeting announcements.)

Brendan Smith started the Salon with a great overview of the challenges faced by contemporary paper-based national Health Information Systems (HIS), from delayed initial reporting, to transcription errors, to the massive time commitment required to analyze the data. In fact, Jamaica clinicians have over 500 forms to record their activities, and Indian clinicians typically spend every Saturday recording the events of their week.

Health information system in practice

With the obvious drawbacks to paper systems and the allure of massive efficiencies expected with automated ICT-based systems, many countries are looking at or actively moving to electronic national Health Information Systems. Vital Wave Consulting identified 5 levels of sophistication that countries go through in their HIS automation progress:

1. District Routine Health System Data Reporting
   Manual tallies from activity registers using redundant paper forms reviewed only at higher Ministerial levels
2. Optimized District Health Data
   Still paper-based, but indicators rationalized and simplified to reduce collection burden and increase data quality
3. Electronic Storage & Reporting of District Health Data
   Manual data entry from log books to electronic forms for stronger analytics, requires basic computer literacy and continuous tech support
4. Incorporation of Operational IT Systems
   Automatic data capture in routine transactions where indicators are automatically generated with access to information from all levels
5. Fully Integrated National Health Information Systems
   Data from all key sources (public & private), governed by explicit national policies, creating a strong data-driven culture with sense of ownership at all levels

They also categorized the studied countries into each level, with one notable exception. Not a single country made it to Category 5 - Fully Integrated HIS. In discussions with Technology Salon attendees, it was our opinion that no country - developing or developed - is in that category either. And skipping ahead to Vital Wave's report conclusions, shows us why.

In their analysis of national HIS efforts, Vital Wave found five key metrics to success, which should look familiar to anyone involved in change management for large organizations:

• Integrate an HIS in conjunction with broader health system reforms
• Streamline data collection and reporting as a first step
• Plan for hidden costs and staff resistance
• Cultivate a data-driven management culture
• Create change management and incentive structures

To bring home the point about change management vs. technology, let's walk through the India HIS example Vital Wave gave from their own field research.

India's National Rural Health Mission is rolling out a health information system to gather data from the block level - an administration point, usually a hospital-type community health center, that has local and rural clinics beneath it. These clinics will still use a paper system, but 3,000 data points have been reduced to 200. These paper forms will be entered by dedicated data entry staff at the block level, and eventually block level clinicians and higher will enter their own data directly.

Category 3 advance

While this system will greatly increase accuracy, timelines, and efficiency overall, Ministry staff were the most proud of the data point reduction. It was seen as the greatest challenge and accomplishment of the HIS - more than even the computerization of the process. In fact, that single act alone took the personal intervention by India's Health Secretary as there was huge resistance to giving up indicators.

Each indicator was seen by the person tracking it as integral to their work, maybe even to their continued employment, so reducing the number of indicators, while creating benefit for the whole, also created intense fear and uncertainty in the Ministry rank and file. In addition, the reduction of errors also posed its own problems. With more accurate information, long-held assumptions, some of which careers were tied to, were revealed to be false. Salon participants reported instances of Ministry staff, even Ministers themselves being fired when the new HIS data reflected a different reality than previous systems.

So deploying a national health information system successfully does not require the high-end technology resources available to richer countries. The major hurtles to successful national health information systems are human, not high-tech. Having a clear goal of improving data quality, and a solid change management approach to achieve is the critical success factor. And this can be accomplished in countries as varied in resources as Belize, India, and Sierra Leone.

It often seems that there are as many health information systems (HIS) as there are governments - from custom legacy systems to new web-based applications. But which governments are using a HIS, what system do they employ, how has it helped them, and and what can we all learn from their experiences?

Health information system in practice

For the next Technology Salon, we'll focus on a recently-completed study by Vital Wave Consulting that surveyed the global landscape of national HIS ecosystems in the developing world. This study was sponsored by the Bill & Melinda Gates Foundation to:

1. analyze the landscape of national HIS ecosystems
2. review prominent examples of HIS implementations
3. identify critical success factors to strengthen health outcomes

We'll have Brendan Smith of Vital Wave Consulting lead us through the report highlights, India case study, and an accompanying online HIS forum with an engaged discussion around the various health information systems, fueled by a hot coffee and Krispe Kreme donuts sugar rush.

National Health Information Systems: Who Uses What, Where?
June Technology Salon
Friday, June 26, 8:30-10am
UN Foundation Conference Room
1800 Mass Avenue, NW, Suite 400
Washington, D.C. 20036 (map)

Do note that this Salon is on Friday morning, instead of Thursday, seating is limited and the UN Foundation is in a secure building. So the first fifteen (15) to RSVP will be confirmed attendance and then there will be a waitlist.

Epidemics and a shortage of healthcare workers continue to present grave challenges for governments and health providers in the developing world. Yet in these same places, the explosive growth of mobile communications over the past decade offers a new hope for the promotion of quality healthcare - billions now have access to reliable technology that can also support healthcare delivery.

Mobile-empowered healthcare (DataDyne)

How can this access to mobile technology, radically improve healthcare services - even in some of the most remote and resource-poor environments?

Please join Inveneo's Eric Blantz and Vital Wave Consulting's Dr. Karen Coppock in a discussion around mHealth - how technology can empower better and more efficient healthcare services throughout the developing world, with an emphasis on mobile and cellular technologies.

Of special focus is the recent United Nations Foundation and Vodafone Foundation Technology Partnership report, mHealth for Development, authored by Vital Wave Consulting

Opportunities for mHealth in Development
March Technology Salon in San Francisco
March 3rd, 8:30-10am
@ Inveneo
972 Mission Street 5th Floor (map)
San Francisco, CA

Please RSVP as we only have seating for 15 and after that, there will be a waitlist.