comments interspersed below, i left some notes i was annotating down so ignore or glean from them as you please.<br><br><div><span class="gmail_quote">On 3/16/08, <b class="gmail_sendername">Leo Anthony Celi</b> <<a href="mailto:leoanthonyceli@yahoo.com" target="_blank" onclick="return top.js.OpenExtLink(window,event,this)">leoanthonyceli@yahoo.com</a>> wrote:</span><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;">
<div>Hi,</div> <div> My flight is at 6:30 PM so I was planning to get to the airport by 4:30 PM. Even if I get to the airport by 4 PM, I'm probably queueing up for about an hour given it's an international flight.</div>
<div> Go ahead without me. My main questions are:</div> <div>1. How important is real-time decision support functionality to them? If they think it is key, who will provide the on-call service? Doctors in Lusaka? Doctors in the US? How will this be possible given the time difference between Zambia and the US?</div>
</blockquote><br>it's mixed. It might not be a high percentage of cases. but the dr. reiterated that they want feedback within 30-60 minutes of an image sent to teh central server.<br><br>text information to patient personal mobiles.<br>
Additional QA process in addition to just comments on images?<br>
UNAIDS on sending images internationally?<br><br><br>9+ countries from pepfar, will <br><br><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;">
<div>2. How do the doctors on-call want to be notified of the need for decision support? The workflow needs to be granularized fully. Will the doctor on-call just want to ring the nurse who sent the image? A use case diagram will be helpful. How do we capture and document the
decision/information flow? This is improtant for QA. </div></blockquote><div><br>I'm thinking nothing is going to stop a doctor from calling a nurse directly. There's a paper from a SUNY dermatoliist who does his whole remote derm. work from the ER vai MMS and phone calls. So there is a precedence for this kind of stuff.<br>
<br>But anyway, the scope I'd say for the initial implementation is just going to be this, the software is only 1 way, nurse to server, server messages Doc of info via MMS and/or SMS alert. Doctor will call nurse for their findings. Doctor must then follow up on server since the server will show that it was not updated on the server side, and the server can't know a call was made, so a doc must go in and self acknowledge that he made a call and put the diagnosis in.<br>
<br>Future implementations I'd say that the doctor will have special software on the phone. We can mandate this since CIDRZ is in full control of its docs, and have the doc be able to electronically update his findings on the phone and msg them back to the nurse. <br>
<br></div><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;"><div>2. What other functionalities do they want? How do they want to carry on the weekly image reviews that they have now? Are the doctors planning to continue travelling to each area of the country as the programme is rolled out? Or do they envision a tele-medicine type image reviews?</div>
</blockquote><div><br>This is a tough question from this vantage point. Once again, nothing is going to prevent the docs or other nurses from going afield. This will have to be discussed as part of their institutional regimen. However, as far as the electronic system goes, I'd say that we should be writing the server component as if it was the primary means of QA/QI by having docs and nurses discuss over their images. It's not the scope of this implementation to look into screen sharing or whiteboards for conferences to discuss the same image. Assume asynchronous discussion based communication.<br>
</div>'q's<br>changes compatible w/ invasive cancer<br>where does the lesion go? inside/out?<br>> 75% cervix area<br>demog<br>treatment history?<br>hiv status<br>cd4 count?<br><br><br>how do we define metrics?<br>
evaluation of nurses. track their progress over time. how close they come to the expert.<br><br>num of patients they refer<br><br>put cervical lesions as same categories as attendings.<br><br>digital pathology italian pathologists w/o borders<br>
use as comparative for cancer accuracy for histology<br><br><br><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;"><div>3. How are they envisioning implementation? I presume they'll pilot the real-time functionality in a small area? I've presumed from my previous question that it will be a roll-out implementation across the country. </div>
</blockquote><div><br>Yeah. As far as my experience has gone in Zambia, the rollout will probably start local and/or trusted nurses. In particular one nurse who's really good is moving to the other side of the country. She'd be an ideal candidate for remote rollout.<br>
</div><br><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;"><div>4. What other QA processes should we put in place for the pilot apart from a record of the exchange and transfer of information? for the actual implementation?</div>
</blockquote><div><br>I think this might be part of how we build up the phone software to include 2 way communication back? Electroncially capturing the transaction in realtime will probably help QA/QI in the long term.<br>
</div><br><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;"><div>5. We should also come up with both process and outcome metrics that we will track as we implement it from one area to another.
These are important if CIDRZ really wants to become established as the center of training in cervical cancer screening. This is my area of expertise and would be happy to work with the CIDRZ folks.</div></blockquote><div>
<br>Metrics as discussed in the call were discussed as thus. For a pilot evaluation we will document the ratio of diagnoses the nurses do. Positive, negative, indeterminate. Next, we will also track the accuracy of the diagnoses the nurses put as compared with the doctors. Presumably maybe there needs to be a QA/QI process that evaluates nurse/doctor findings and assigns a score for each diagnosis after the fact?<br>
</div><br><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;"><div>6. Are they going to use the same nurses as we roll out from one area of the country to another? If not, how many nurses need to be trained? I presume the core group of nurses will be responsible for training the nurses in other areas of the country? Have they given this a thought?</div>
</blockquote><div><br>The training and such is CIDRZ' responsibility. They have already a well defined 8 week training program for nurses. Their rollout for training and other things are contingent on funding and other in country issues. However, the training of practitioners and experts in countrywide deployments is CIDRZ' expertise in country.<br>
</div><br><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;"><div>7. What sort of operational and technical risks are involved in the project? How can we minimize these risks? Do we have contingency plans for those that are most likely to be encountered?</div>
</blockquote><div><br>One risk/uncertainty I'm concerned about is the reliability of the cellular/internet infrastructure. For keeping the ministries of health pleased (as well as general privacy concerns appeased), we may have additional overhead on our data that may make communication difficult. So, finding contingency plans for this sort of thing looks to be important as well.<br>
<br><br> </div><br><blockquote class="gmail_quote" style="border-left: 1px solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex; padding-left: 1ex;"><div> Andres, I leave the oral presentation in your hands. Daniel Myung, Andres will be presenting on Tuesday in case you haven't been informed yet. Andres, please post
a blog regarding the conference call and the comments/suggestions of the instructors and the rest of the class. I'll make it up when I get back. </div> <div>Cheers,</div> <div>Leo<br><br><b><i><br></i></b></div></blockquote>
</div>