eCompliance: A game changer that can scale TB care internationally and prevent MDR TB

1© Operation ASHA

2

India- the emerging superpower?

MDR-TB Treatment costs 50-200 times more than normal treatment

Drug Resistant TB in India

More than 100,000 estimated cases of drug resistant TB in India, less than 3,000 identified.

12 cases of extremely drug resistant TB (XXDR or TDR) recently found in India.

In a recent study, only 3 out of 106 practitioners issued an appropriate prescription for drug resistant TB.

3

100% DOTS coverage?

“DOTS alone is not sufficient to curb the TB epidemic in countries with high rates of MDR-TB.”

- Stop TB Working Group

“Electronic datasets are needed to facilitate accuracy and analysis of data.”

-WHO (2011)

Horrifying Scenario

2015: 1.3 million MDR cases, needing $16 billion

2050: 50 million TB cases.

2050: 10 million deaths, 2 million of these will be by MDR-TB

4

Solution- a local, deep model with community empowerment & eCompliance for low cost and high impact model

• Accessible DOTS - Strategically locates TB centers in convenient, high-traffic areas

• Community members hired as providers• Rigorous Training• Performance based incentives• eCompliance biometric terminals.

55

PROBLEM

• Unsupervised doses being given• Missed doses and default • Missed doses are not tracked• Time lag between missed dose

and follow-up• Inaccurate record keeping• Data fudged deliberately• Absenteeism among staff

eCompliance- “Turning the Tap Off” on MDR-TB

SOLUTION

• Finger print confirm the presence of a TB patient as well as the staff

• Patients/ staff scan their fingerprint at the treatment center

• This creates indisputable evidence of patient interaction, initial house visit and follow up of each missed dose

• One cannot ‘fudge’ a fingerprint!

PRIMARY OBJECTIVE - To ensure accuracy and adherence

6

Workflow with eCompliance

Patients are registered by scanning fingerprint At every visit, patients scan finger, creating a verifiable log of patients who were present

• Runs on commercially available, ‘off-the-shelf’ components• An inexpensive android phone• A commercially available inexpensive finger print reader

• Software developed by Operation ASHA, with initial support from Microsoft Research

7

Features of eCompliance

• Color coding shows that a patient has been successfully logged in

• The simple interface uses a minimal amount of text• Can be easily translated into other languages• Geo-tagging of all Supervised Doses

Providers can quickly identify which patients have• missed their dose• So they can follow up, within 48 hours, provide dose,

further counseling and convince the patient to join the therapy again.

8

How eCompliance Works

Electronic Reporting System

Online SMS Gateway

Patients, Health Worker & Program Manager

Dose missed!

eCompliance Tablet

Fron

t End

Back

End

The Front End • Uses only off-the-shelf

components A fingerprint reader An Android Tablet

The Back End• SMS Gateway for Sending

Alerts• Electronic Medical Record

System• Central Database

SMS

Encrypted Data

9

eCompliance Guru: Web-based reporting system at the back-end

10

Third party replication by Columbia University/ Millennium Villages in UGANDA in June 2012• Outstanding results: Death + Default rate down to zero from > 16% in the preceding year

Replication by Researchers at Columbia University/ Millennium Villages Project in Uganda

CHWs in Uganda being trained on eCompliance

11

eCompliance: Implementation

Results• Default <3%• Over 6,777 patients enrolled so far• Over 2,68,398 visits logged• Over 5,000 visits logged every month

Terminals used in South Delhi since 2010

Terminals installed in Bhiwandi, Jaipur and Mumbai centers in since 201234

25

84Terminals installed in 5 cities in MP (Bhopal, Jabalpur, Gwalior, Gwalior Rural, Indore, Sagar) and 3 cities in Chhattisgarh (Raipur, Bilaspur, Durg, Bhilai) and Bhubaneshwar in Odisha

Lessons Learned• Patients are not hesitant to give their fingerprints• Patients perceive technology as a sign of high quality of treatment

159 Total no. of terminals installed by the end of Aug 2013

Of which so many Android terminals have been installed in South Delhi and Dharavi , Mumbai since July and Oct 2013

30

Of which 3 terminals were installed in Uganda in 2012 and 2 in Dominican Republic in Jun 20135

12

PATIENT AND COMMUNITY LEVEL• Positive impact on the psyche• Improves motivation• Seen as dedication towards quality treatment• Interest generated by technology intervention in disadvantaged areas• Re-enforces belief in the government and DOTS• Indirect benefit- discussion of health issues

AT LEVEL OF FIELD STAFF• Ensures integrity of DOTS: eliminates unsupervised doses, which are otherwise the norm

across the world• Eliminates human errors in management of DOTS. For example, if a patient comes on the

wrong day, eCompliance automatically reminds the counselors and prevents such occurrences

• Improves skills• Makes counseling easy, ie. easier to convince patients• Accurate reporting and up-to-date intelligence

– Eliminates human error• Saves time spent in going through paper records• Real-time records allows counselors to target counseling• Produces all reports automatically.• The above results in 30% improvement in productivity and reduction of costs, which more

than pays for the cost of eCompliance terminals.

The Key Benefits of eCompliance

13

The Key Benefits of eCompliance

MANAGEMENT LEVEL• Accuracy of records• Transparency• An accurate platform for monitoring and evaluation of the core

program– Eliminates absenteeism, late coming of staff– Prevents tampering with patient data

• Transparent treatment supervision• Ensures proper payment of performance based incentives

THE PUBLIC HEALTH PERSPECTIVE• ENSURES DOTS is being delivered• Halts the development of drug resistance due to default.• Provides unlimited quality data for future research

14

Challenges and the solutions

STAFF Fear of micro-monitoring Fear of losing jobs to computers Fear of theft, breakages

PATIENTS Fear of electric shock!

TECH TEAM Accuracy of recognition of finger-prints Computational ability

- Privacy of patients and data- Maintenance- Software and hardware failure, viruses etc - Need based ongoing system analysis- Security measures needed to prevent tampering- Reconciliation of data

15

Cost Effectiveness

Total cost of each eCompliance terminal = $245 (Rs. 14,900)

Cost per patient = $2.66 (Rs. 162), which is more than offset by increased productivity (each unit will treat 92 patients over 2 years: average at OpASHA)

Component Cost

Android Tablet $ 140 (Rs. 8,500)

Fingerprint Reader $ 65 (Rs. 4,000)

Internet Plan (per year) $ 40 (Rs. 2,400)

16

Immediate need: multilevel use of eCompliance

Expected Benefits 1. At all levels- ensure complete, comprehensive, real-time and

transparent data2. Microscopy centers- will send alerts to CHWs, public hospitals

to prevent “loss” after detection3. Public hospitals4. Referral labs5. Drug sellers - incorporate in DOTS to prevent misuse of drugs6. Incentivize patients ( for example a10 cents talk time for each

dose taken or a regularly increasing incentive!)

This will incorporate1. All nationwide DOTS centers2. Microscopy centers3. Referral labs4. Public hospitals5. Drug sellers6. Quacks7. Pharma-companies 8. Any individual/ organization

that is involved in TB control

17

Conclusion- the way ahead

Develop eCompliance software further for System analysis for daily dose regimen Adherence for MDR-TB, ART Integration with MCH, midday meals etc NCD, especially integration with DM Zero literacy areas (use icons and audio tracks)

The fight goes on…