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Can Mobile Phones Improve Health In Developing Countries?

Screen-shot-2010-11-05-at-10.16.57-AM.pngThe potential of mobile phones to improve health is most acutely visible in developing countries. iMedicalApps covered the recent mHealth Summit, where there were many inspiring demonstrations of how voice and simple text messages can have a profound effect on the health of those countries’ citizens. Jhpiego has successfully worked on these problems for three decades and was recently awarded a $100m grant. James Bon Tempo has extensive experience in this field and we are thrilled that he is sharing his insights with the readers of iMedicalApps.

This is a guest post from James BonTempo.

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Mobile Health In Developing Countries

I am a user and an implementer of technology, not an inventor or developer, so my constraints, challenges and requirements are different than those of many attendees of the recent mHealth Summit. And for others like me who work in international aid and development, mobile technology is simply a tool, and one of many in a large toolbox that includes various best practices and proven approaches. At Jhpiego (an affiliate of Johns Hopkins University), we have piloted a number of different mobile interventions — from simple SMS to Java & smartphone-based applications — but the challenge for us is to identify the most appropriate technologies, the tools that will help us to strengthen health systems in limited resource settings most effectively and most efficiently.

201101110730.jpgOf course, the term “appropriate technology” is awfully loaded and there are various respects in which something can be deemed appropriate. There’s appropriate from the user’s perspective — careseeker, healthcare provider, ministry staff — and their ability to adopt and integrate the technology into their existing routines. There’s appropriate in terms of being based on the existing technological infrastructure and consistent with local human resource and support capacity. And there’s appropriate in terms of the technology’s ability to meet program goals and objectives and to do so in a cost-effective manner.

For us at Jhpiego, and those at organizations that work in similar geographic and socioeconomic contexts, appropriate is largely about simple and pervasive technologies. Why? Because, despite what some might want us to believe, while technology is moving fast it’s not really doing so in the developing world. At least not the more advanced technologies like smartphones and 3G access, especially when you start looking beyond urban population centers and the upper class.

For example, where is the $100 Android phone that was supposed to be available in Kenya? The announcement came out last year, but you still can’t buy one on the street. (Perhaps I should have nominated it for the Wired Vaporware Awards.) And even when it does arrive you’ll probably only be able to buy one in Nairobi, maybe Mombasa or Kisumu — and most people won’t even be able to afford it.

I think what we actually need more of right now is process and program implementation innovation more so than new technologies or software application development. And what do I mean by that? I mean that we need to explore further the affordances of the most pervasive mobile phone functions: the voice and SMS functionality that’s available on each of the 4 billion devices out there. And we need to identify specific opportunities to integrate the application of these basic functions into our approaches in a way that supports and strengthens them. I believe there is a lot of room to explore in this space and it is here that we need a “proliferation of pilots,” where we need to “let a thousand flowers bloom.”

What we don’t need are more pilots to tell us what we already know: For example, that the acceptance rate is high for providing health information via text message, that well-designed and targeted text messages can improve drug adherence, or that having a call center can increase utilization of counseling and other services. We need to take these things that we know work — and, by the way, there has to be an easy way to find out about them — integrate them into our health system strengthening approaches and scale them.

201101110732.jpgIn one of the keynote presentations at the Summit a comment was made about the “power of making a phone call” and I’d like to share a quick anecdote about that. Early last year I had a conversation with a nurse from Kenya and she was telling me about her first experience attending a birth. As she was a recent graduate and this was her first time doing this she was understandably nervous, anxious and a little unsure of her abilities. So, what did she do? She took her mobile phone out of her pocket and called her mother who, as it happens, is also a nurse. Her mother was able to provide coaching and support remotely, just when it was needed, leading to healthy and happy outcomes for everyone involved.

While it may not be immediately recognizable as such, this is a great example of informal learning and real-time performance support, and it epitomizes the kind of simple mobile technology application we need to explore more deeply. This sort of just-in-time learning leverages the real strength of mobile and wireless technologies — collapsing time and space — and it’s rooted in the application of the most basic features that are available on every phone in the world. And further, it democratizes and individualizes the technology’s use, allowing anyone to target the application to where and when it’s most relevant and address the context-specific needs of the user.

As a technologist, I can certainly appreciate breakthroughs and advances in technology. But there are some very simple things that can be done, using existing and pervasive technologies, that can make a big difference. And working in some of the most resource-limited settings around the world that’s where I believe we need to be focused. Because it’s in these places, in these contexts, and following these sorts of approaches, that we’ll be able to have the most impact.

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James BonTempo is a learning technology advisor at Jhpiego and can be reached at “jbontempo at jhpiego.net.” If you are interested in these questions, then you must also follow his blog: Linearity of Expectation.

*This blog post was originally published at iMedicalApps*


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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