Meeting Minutes, April 2012

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mHealth Working Group Monthly Meeting April 26th from 9 00am 11 30am EDT Association of Reproductive Health Professionals 1901 L Street NW Suite 300 Washington DC Agenda 1 Where Are They Now Past Presenters and Lessons Learned a CommCare by Neil Lesh Dimagi b m4RH by Heather Vahdat FHI360 c m4QI by Pam Riley Abt Associates and James Bon Tempo Jhpiego see Presentation Slides d CycleTel by Meredith Puleio IRH Georgetown see Presentation Slides 2 Frameworks for Lessons Learned in mHealth 3 Landscape Analysis of mHealth Projects Thanks to ARHP for hosting the April 2012 meeting The presentations that accompany these notes as well as those from previous mHealth Working Group meetings are available on the mHealth Toolkit at http www k4health org toolkits mhealth mhealth working group 0 For questions or comments please contact Kelly Keisling Keisling kelly gmail com or Laura Raney lraney fhi360 org co chairs of the mHealth Working Group The next meeting of the mHealth Working Group will be hosted by Save the Children to discuss organizational strategy for mHealth The meeting will be held on Tuesday May 22nd 9 30 am 11 30 am EDT at 2000 L Street NW Suite 500 The meeting is available remotely in US or via Skype 1 866 386 4210 international 1 433 863 6601 code 634 879 6591 Discussion is invited on participant experiences with organizational strategy in e mHealth Introduction to Past Presenters and Lessons Learned Where Are They Now As mHealth continues to evolve we review with past presenters how these mHealth projects have evolved with the field Presenters discuss their ongoing progress and lessons learned in mHealth We then discuss lessons learned within frameworks for issues in mHealth 1a CommCare by Neil Lesh Dimagi Since its September 2009 presentation to the Working Group Dimagi has shifted from a focus on single projects to a product orientation Dimagi s 2009 presentation is available at http archive k4health org toolkits mhealth September 9 2009 The CommCare product has expanded in reach and features It is used by 1700 community health workers CHW in 12 countries including 10 states in India CommCare now includes multimedia audio images video Adoption is supported by standard pricing implementation plans and a total cost of ownership model Deployment is facilitated by authoring tools allowing non programmers to deploy CommCare Four studies will also be published in 2012 demonstrating intermediate outcomes in access quality experience and accountability of care These will be accompanied by two larger studies to be completed in 2013 Lessons Learned and Discussion The product approach has accelerated scale up of CommCare Dimagi has developed standardized tools and approaches which allow organizations to more quickly and easily start using CommCare Dimagi can more easily support its users because it has only one code base to support Finally organizations can deploy CommCare on their own without software programmers It has also become clear that greater emphasis is needed on making data actionable This is because most organizations are not used to getting real time data and thus are not prepared to utilize it Technology amplifies human dimensions such as interaction with supervisors Thus systems work if they are driven by someone rather than merely by automation Likewise human capacity is needed to use technology capacity For example audio messages needed to be supported by CHW training on message topics Underlying these issues is the need to provide organizational capacity building in mHealth This includes capacity for data management program planning logistics and project management It also includes technology capacity and computer literacy though these are not critical gaps and CommCare is designed to reduce dependence on these 1b m4RH by Heather Vahdat FHI360 Mobile for Reproductive Health m4RH was launched in Kenya in 2009 and replicated in Tanzania in 2010 It supports information seeking for family planning methods and contraceptive adoption through features such as a shortcode query of names and locations of clinics The research pilot was completed in June of 2011 and is currently under analysis FHI360 discussed evaluation techniques for m4RH in October 2011 at http archive k4health org toolkits mhealth october 20 2011 Initial results demonstrate m4RH s reach to women men and couples including those in rural areas Open ended questions on how m4RH impacted family planning were texted to m4RH users and received a 12 18 response rate The project is still in operation in Kenya and Tanzania as part of the USAID funded Program Research for Strengthening Services PROGRESS project M4RH is currently being promoted as part of the Johns Hopkins Center for Communication Programs CCP in Tanzania Jiamini campaign which was initiated on April 2 2012 This partnership provides wide scale promotion of m4RH and has resulted in a substantial increase in m4RH usage from approximately 30 000 hits during the pilot research period August 2010 June 2011 to approximately 50 000 additional hits in the first three weeks of the campaign Currently the m4RH team is working on adapting m4RH for a youth focused intervention in Rwanda and on efforts in Tanzania to expand m4RH content to include messages on contraceptive continuation The m4RH program was selected as one of Women Deliver s 50 most inspiring ideas and solutions that are delivering for girls and women for 2012 in the area of Technologies and Innovations Lessons Learned and Discussion Partnerships are critical for project success These include programmatic partners such as CCP and Pathfinder as well as ICT partners such as Text to Change and D Tree FHI360 discussed health ICT partnerships for m4RH in December 2010 at http archive k4health org toolkits mhealth december 13 2010 Promotion is also a crucial factor in scale up A question was raised about emergency contraception clinic services and mobile phone ownership all being skewed toward higher educated populations but FHI360 s preceding research in Ghana found that education bias was not great for emergency contraception Interactive voice response IVR was raised as an alternative format for illiterate users M4RH can reach illiterate users through literate peers that read SMS for users but this could create challenges for confidentiality FHI 360 is planning to investigate options for IVR as part of future efforts but IVR is expensive particularly for programs in Africa and we feel confident that m4RH is able to serve a large portion of their target populations A point was made that a future concern may be that competing spam can distract from SMS and related legislation can limit its use in some countries m4RH may be less vulnerable to these challenges since it is a pull system currently using non digital promotion to encourage user registration m4RH has had steady SMS use and spikes after promotions It also has repeat users as indicated by the telephone numbers that form unique IDs There are also reports of users sharing m4RH messages with peers by forwarding SMS m4RH is now focused on sustainability including costs and significantly content management to ensure quality and overall project coordination Meeting participants also suggested the opportunity for advertising messages to provide revenue for financial sustainability Mobile network operators MNO may be an important partner for sustainability but their expectations for traffic levels are very high MNO investments in mHealth projects are often short term creating an unclear precedent for long term sustainability FHI 360 has explored both of these options and will continue to do so as part of their larger sustainability discussions which are currently on going 1c m4QI by Pamela Riley Abt Associates and James Bon Tempo Jhpiego Preparations for m4QI were presented a year ago to discuss SMS assessments and reminders as a cost effective means of reinforcing training of field staff March 2011 discussion available at http archive k4health org toolkits mhealth March 23 2011 As part of the USAID funded SHOPS project the m4QI pilot has since used a version of FrontlineSMS to send daily messages for eight weeks on four topics to 34 family planning providers at six locations of Marie Stopes International in Uganda A qualitative process evaluation found that 86 of messages were successfully delivered The pilot was able to use assessment questions via SMS to identify knowledge gaps with actionable data as well as self reported behavior change for all indicators Users said they received instant and clear feedback for wrong responses They also said the project was a constant motivator of hand washing a project goal Marie Stopes Uganda is planning a national roll out of m4QI to staff social franchisees and outreach partners m4QI code is being revised for alpha testing of FrontlineSMS Learn which is targeted for public launch in May 2012 Lessons Learned and Discussion The pilot experienced technical problems as intermittent system failures A low response rate 19 was attributed to duplicate messages sent but only answered once Formatting errors on true false questions also caused rejections of other answers The program also required the right kind of modem and messages stopped when payments stopped for the modem Compatibility of FrontlineSMS with Windows was also a challenge No one was available onsite to troubleshoot these issues requiring calls to US based staff at two in the morning A local IT provider is thus sought to support future efforts The local capacity needs platform processes and partnerships have evolved with the pilot A new version of FrontlineSMS core platform is in development The pilot also needs to incorporate new staff processes and policies for quality assurance Unintended results of the m4QI pilot include mobiles being banned from the procedure room Partners also evolve during a pilot as FrontlineSMS transitioned from a flexible open source group to an established business with requirements for brand preservation and quality assurance review M4qi started before change much heavier review by FrontlineSMS team what released on what had their brand Resources are also needed for incorporating and supporting Learn within the FrontlineSMS family of applications FrontlineSMS was mentioned as a good learning tool and easy to use for small local NGOs since the NGO is empowered to use the technology how they wish However it would face challenges in national rollout FrontlineSMS is an open source platform supported by an IT community Consequently the principle cost is not software development but instead program planning and supervision 1d CycleTel by Meredith Puleio IRH Georgetown CycleTel is a mobile health service in India that uses text messaging to facilitate use of the Standard Days Method of family planning In January of 2011 IRH presented on the formative research that contributed to the design of CycleTel See http archive k4health org toolkits mhealth january 19 2011 Since then CycleTel has progressed through proof of concept automated testing and business planning as it progresses toward partnership development and scale up in 2012 Pilot results among 653 exit interviews found the mHealth service was timely 87 4 private 79 5 and easy to use 78 7 Lessons Learned and Discussion CycleTel s development has been a step wise systematic and iterative process The technology platform has evolved from initially using FrontlineSMS to building out an automated service that relies on a local SMS gateway Partnerships will become more complex as IRH implements a business plan for the sustainability of CycleTel After evidence was determined that the service works IRH developed a business model with support from the Boston Consulting Group in India This includes identification of market segments and size industry analysis go to market strategy financial modeling and business scenarios high and low achievement cases depending on the level of donor investment In the India context it is more attractive to work with telco aggregators than mobile network operators MNO for this particular service It would be difficult to compete with hundreds of local content providers for MNO attention Conversely there are several capable aggregators in India with a mHealth focus that work across MNOs and are keen to partner with IRH IRH contributed to a report coauthored by the mHealth Working Group on public private partnership in mHealth at http archive k4health org toolkits mhealth december 7 2011 To reach a critical mass 100 200K users CycleTel would first require anchor funding for broad based promotion via a mix of channels including high engagement approaches face to face to attract customers CycleTel uses a direct to consumer approach though there are alternative examples of mHealth projects using partner organizations in family planning for promotion It is important to note that CycleTel is promoting access to the Standard Days Method of family planning which does not necessarily require relying on family planning services through partner organizations CycleTel also provides a call center to answer user questions about the service as well as to provide information about other family planning options However note that the call center is one of the most costly components of the operation 2 Frameworks for Lessons Learned in mHealth The update from past presenters shares a range of lessons learned in mHealth A clear framework for issues would help synthesize lessons from the growing and evolving body of mHealth projects A variety of frameworks have been developed for health information technology in general and mobile technology in developing countries specifically A number of practical implementation issues are framed in Unintended Consequences of Computerized Provider Order Entry including additional work workflow issues new kinds of errors persistence of paper forms changes in communication patterns user emotions changes in the power structure continuing technology demands and overdependence on technology Relevant organizational issues are also categorized by Managing Technological Change Organizational Aspects of Health Informatics These include organizational readiness design issues project planning and management technology acceptance personal stress organizational leadership and politics and evaluation Challenges and factors for ICT success were described in Capturing Technology for Development An Evaluation of World Bank Group Activities in Information and Communication Technologies These include quality of design of ICT breadth of technological approach to ICT implementation according to plan and modifications coordination of IT initiatives and investment strong government implementation capacity government commitment to ICT implementation capacity strength and effectiveness of management change management and ICT procurement Meeting participants suggested additional considerations for an issues framework to support planning in mHealth These include defining the prerequisites for a successful mHealth program as well as which partners need to be involved A clear explanation of how mHealth contributes to health outcomes would be helpful Knowledge management is also useful for supporting these efforts mHealth should be part of a national strategy and should be integrated with existing information systems Business models are important particularly when working with mobile network operators MNO Participants said guidance is needed on how to design and manage mHealth projects IT organizations can provide counsel on related IT issues though broader and impartial guidance is needed on the strategy design and management of mHealth projects 3 Landscape Analysis of mHealth Projects An initial inventory and landscape analysis of mHealth projects has been performed with the 10 organizations on the mHealth Working Group Advisory Board The initial inventory captures over 150 mHealth projects in 50 countries Meeting participants suggested ways to release the inventory of mHealth projects and to invite contributions by members of the mHealth Working Group It was suggested to keep the inventory simple and easy to receive new submissions It was also suggested to make the data actionable by including the country and status of a project Data could be filtered group monitored or unobstructed for easy submission Further information will be announced about the mHealth Working Group inventory and landscape analysis of mHealth projects About the mHealth Working Group Founded in 2009 the mHealth Working Group is a collaborative forum for convening knowledge sharing promising practices collaboration capacity building advocacy and member leadership Composed of more than 675 individuals representing over 200 organizations in 35 countries the mHealth Working Group seeks to frame mobile technology within a larger global health strategy By applying public health standards and practices to mHealth we promote approaches that are appropriate evidence based interoperable scalable and sustainable in resource poor settings The mHealth Working Group is facilitated and supported by USAID s K4Health Project Our advisory board includes Abt Associates Catholic Relief Services FHI360 Georgetown University Institute for Reproductive Health Jhpiego John Snow Inc Johns Hopkins Center for Communication Programs Management Sciences for Health Population Services International and Save the Children Minutes from monthly meetings as well as more information about the group are on the mHealth Toolkit at http www k4health org toolkits mhealth mhealth working group 0 Interested colleagues are welcome to receive future announcements by joining the listserv at knowledge gateway org mhealth mHealth Working Group Meeting Participants April 26 2012 Name Organization Gwendolyn Morgan APHRC Aleya Horn Kennedy ARHP Linda Carr CDC Adele Clark CRS Ann Jimerson FHI 360 Katie Cretin FHI 360 Laura Raney FHI 360 Mike Pezone FHI 360 Rick Doerr GBI Andrew Wyborn Greenmash Lauren Wu HHS Rebecca Kohler Intrahealth Meredith Puleio IRH GU James BonTempo Jhpiego Kirsten Bose JHUCCP K4Health Farhan Bandeali Johns Hopkins University Heather Rosen Johns Hopkins University Mike Frost JSI Kelly Keisling mHealth Working Group Jo Vallis NHS Education for Scotland Julie McBride PSI Margot Mahannah PSI Jeanne Koepsell Save the Children Maria Klein Trinity Caitlin Chapman University of Washington Nancy Newton URC Megan Matthews USAID Trisha Phippard UWO Taroub Faramand WI HER Rosie Calderon World Vision Bill Philbrick
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